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.

Child's Name

Date of Birth

Date

Which Learning Center do you wish to enroll your child in?

Parkway Learning Center (3300 Parkway St. NW Canton, OH 44708)14th Street Learning Center (2213 14th St. NE Canton, OH 44705)

First Day at Program

Date

Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Format: (000) 000-0000.

Parent/Guardian's Name #1

Relationship to Child

Address same as child's

YesNo. If selected, please add.

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

Format: (000) 000-0000.

Email Address (if applicable)

example@example.com

Cell Phone Number (if applicable)

Format: (000) 000-0000.

Parent/Guardian's Work/School Name

Parent/Guardian's Work/School Telephone Number

Format: (000) 000-0000.

Address

Parents WorkSchool Address

Street Address Line 2

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 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

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number same as child's

YesNo. If selected, please add.

Home Phone Number

Format: (000) 000-0000.

Email Address (if applicable)

example@example.com

Parent/Guardian #2 Cell Phone Number

Format: (000) 000-0000.

Parent/Guardian #2 Work/School Name

Parent/Guardian #2 Work/School Telephone Number

Format: (000) 000-0000.

Parent/Guardian #2 School/Work Address

Address

Street Address Line 2

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 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

Format: (000) 000-0000.

Relationship to Child

Secondary number where Emergency Contact 1 can be reached (if applicable)

Format: (000) 000-0000.

Emergency Contact 2 Name

City

State

Emergency Contact 2 Phone Number

Format: (000) 000-0000.

Relationship to Child

Secondary number where Emergency Contact 2 can be reached (if applicable)

Format: (000) 000-0000.

Name of Physician or Clinic/Hospital

Street Address

City

State

Telephone Number

Format: (000) 000-0000.

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

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

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

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

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

Give Permission to Transport

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

Do Not Give Permission to Transport

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

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.

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE