CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

Ohio Department of Job and Family Services
CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Childs Name
Date of Birth

MonthDayYear
Date
First Day at ProgramHome
Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
ParentGuardian Name 1
Relationship to Child
Relationship to Child
City
State
Zip
Email Address if applicable
example@example.com
Parents WorkSchool Name
Parent's Work/School Telephone Number
Address

Parents WorkSchool Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
Please indicate if this name should be released if a parent/guardian, of a child attending the program/home requests contact information for other parents/guardians.YesNo If you answered yes, please indicate which information above to include on the listWork #Cell #Home #Email
Where can you be reached while your child is in this programhome
ParentGuardian Name 2
Relationship to Child
City
State
Home Address
Zip
Email Address if applicable
example@example.com
Parents WorkSchool Name
Parent's Work/School Telephone Number
Address

Parents WorkSchool Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City
Please indicate if this name should be released if a parent/guardian, of a child attending the program/home, requests contact information Yes for other parents/guardians.No If you answered yes, please indicate which information above to include on the listWork #Cell #Home #Email
Where can you be reached while your child is in this programhome
Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Name
Name
City
State
City
State
Other numbers where emergency contact can be reached (if applicable) Name of Physician or Clinic/Hospital
Relationship to Child
Other numbers where emergency contact can be reached if applicable
Other numbers where emergency contact can be reached (if applicable)
Relationship to Child
Other numbers where emergency contact can be reached if applicable
Name of Physician or ClinicHospital
Street Address
City
State
Telephone Number
Childs Name
Allergies, Special Health or Medical Conditions, and Medical Foods Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home. Does your child have any food, medication or environmental allergies? (check all that apply) No FoodMedicationEnvironmental Please list and explain: Yes - check all that apply
Please list and explain
Does your child's allergy/allergies require child care staff to monitor your child for symptoms to take action if a reaction occurs, or give emergency medication to your child? (check one) No Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed. Does your child have a developmental delay or special health or medical condition? (check one) No Yes - please explain

Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours? (check one) No Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed. Is your child currently using any medication or medical food? (check one) No Yes - please explain

If yes, does this medication or medical food need to be administered at the child care program/home? No Yes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication and a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed for the medical food. Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) No Yes - please explain
please explain
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group? No Yes - written instructions from the child's health care provider must be on file. N/A - program does not provide meals or snacks to the child.
List any history of hospitalization outpatient surgery or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation
List any additional information about your child that would be useful for staff to know such as fears or ways that your child prefers to be comforted
Not applicable List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits.
List any additional information about your child that would be useful for staff to know such as eating or sleeping habits
Not applicable List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs.
List any additional information about your child that would be useful for staff to know such as special routines or behavior needs
Childs Name
Diapering Statement Yes (If yes, skip to Emergency Transportation Authorization section) No (If no, fill out the following:)

The program's policy is to check diapers every program's policy or another: I agree with the program's schedule

hours. Please indicate if you want your child's diaper checked according to the

I do not agree, please check my child's diaper every

Emergency Transportation Authorization

Do Not Give Permission to Transport
Program or Home Name
Program or Home Name
has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment I wish for the following action to be taken
Parents Signature

Clear
Date

MonthDayYear
Date
Parents Signature

Clear
Date

MonthDayYear
Date
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the program's or home's policies and procedures/handbook.Yes

This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care.
ParentGuardian Signatures

Clear
Date

MonthDayYear
Date
AdministratorDesignee Signature

Clear
Date

MonthDayYear
Date
The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all information has stayed the same or changes have been noted. If significant changes are needed, please complete a new form.
ParentGuardian Initials
Date of Review

MonthDayYear
Date
AdministratorDesignee Initials
Administrator/Designee InitialsDate of Review
Date of Review

MonthDayYear
Date
ParentGuardian Initials
Date of Review

MonthDayYear
Date
AdministratorDesignee Initials
Date of Review

MonthDayYear
Date
ParentGuardian Initials
Date of Review

MonthDayYear
Date
AdministratorDesignee Initials
Date of Review

MonthDayYear
Date
Note: This is a prescribed form which must be used by child care providers to meet the requirements to rules 5101:2-12-15, 5101:2-13-15, and 5101:2-14-04. This formmust be on file at the program or home on or before the child's first day of atten dance and thereafter while the child is enrolled.
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