Child Enrollment and Health Information for Child Care

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

Ohio Department of Jobs and Family Services
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Child's Name
Date of Birth

MonthDayYear
Date
First Day at Program

MonthDayYear
Date
Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Parent/Guardian's Name #1
Relationship to Child
Address same as child's

YesNo. If selected, please add.
Home Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number same as child's

YesNo. If selected, please add.
Home Phone Number
Email Address (if applicable)
example@example.com
Cell Phone Number (if applicable)
Parent/Guardian's Work/School Name
Parent/Guardian's Work/School Telephone Number
Address

Parents WorkSchool Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 list:

Work Phone NumberCell Phone NumberHome Phone NumberEmail
Where can you be reached while your child is in this program?
Parent/Guardian Name #2
Relationship to Child
Address same as child's

YesNo. If selected, please add.
Home Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number same as child's

YesNo. If selected, please add.
Home Phone Number
Email Address (if applicable)
example@example.com
Parent/Guardian #2 Cell Phone Number
Parent/Guardian #2 Work/School Name
Parent/Guardian #2 Work/School Telephone Number
Parent/Guardian #2 School/Work Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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 list:

Work Phone NumberCell Phone NumberHome Phone NumberEmail
Where can you be reached while your child is in this program?
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 mustbe able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Emergency Contact #1 Name
City
State
Emergency Contact 1 Phone Number
Relationship to Child
Secondary number where Emergency Contact 1 can be reached (if applicable)
Emergency Contact 2 Name
City
State
Emergency Contact 2 Phone Number
Relationship to Child
Secondary number where Emergency Contact 2 can be reached (if applicable)
Name of Physician or Clinic/Hospital
Street Address
City
State
Telephone Number
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.
Childs Name
Does your child have any food, medication or environmental allergies?

NoYes
If yes, select all that apply.

FoodMedicationEnvironmental
Please list and explain any applicable allergies.
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?

NoYes - 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

NoYes, please explain
If 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?

NoYes, - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.
Is your child currently using any medication or medical food?

NoYes, please explain
If yes, please explain.
If yes, does this medication or medical food need to be administered at the child care program/home?

NoYes - 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?

NoYes - please explain
If yes, please explain.
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?

NoYes - 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.
Child's Name
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.
Non-applicable

Non-applicable
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. If not applicable, write "N/A".
Non-applicable

Non-applicable
List any additional information about your child that would be useful for staff to know such as eating or sleeping habits. If not applicable, write "N/A".
Non-applicable

Non-applicable
List any additional information about your child that would be useful for staff to know such as special routines or behavior needs. If not applicable, write "N/A".
Non-applicable

Non-applicable
Diapering Statement

Fill in this section accurately and completely.
Child's Name
Is your child toilet trained?

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 TWO HOURS . Please indicate if you want your child's diaper checked according to the program's policy or another:

I agree with the program's schedule.I do not agree, please check my child's diaper at the specific interval stated below.
Please check my child's diaper every __________ hours.
Hours
JRC 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 facilty to which my child will be transportated.
Emergency Transportation Authorization

Please sign your name under the selection that determines whether or not JRC has permission to secure emergency transportation for your child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facilty to which your child will be transportated.

DO NOT SIGN BOTH
Signature

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Give Permission to Transport
Date

MonthDayYear
Date
JRC does not have 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 facilty to which my child will be transportated.
Signature

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Do Not Give Permission to Transport
Date

MonthDayYear
Date
Acknowledgement of Policies and Procedures

Fill in this section accurately and completely.
I have reviewed and received a copy of the program's or home's policies and procedures/handbook

YesNo
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.
Parents Signature

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Date

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 attendance and thereafter while the child is enrolled.
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CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE