Ohio Department of Job and Family Services

This form shall be completed prior to the child's first day of attendance and updated annually and as needed.

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

Home Telephone NumberSame as Child's

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

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.

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 EnvironmentalPlease list and explain: Medication Food Yes - check all that apply

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

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

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" mustl 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

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.

Not 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.

Not applicable 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.

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

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

does not have permission to secure emergency transportation for my child in the event of an illness or injury Dowhich requires emergency treatment. I wish for the following not action to be taken: sign both

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

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

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. Date of Review Administrator/Designee Initials Date of Review Parent/Guardian Initials

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.

It is important that our children are as safe as possible. Kiddie Citie has developed a pick-up policy for our staff. We are concerned about your child and who may pick him/her up each day. We must have a list of all possible people who may pick up your child with a maximum of 5 people. If there are any changes, we must be notified when your child is dropped off. The arrangement will be on a day to day basis, if it is a permanent change, a new pick-up policy form must be filed out. A child will not be permitted to leave with anyone not listed on this form unless we have your written permission. We will request to see proper identified if we do not know the person. Please inform the people whom you have listed on this form that they must have proper identification to pick up a child

Please list all persons permitted to pick up your child, the relationship to the child and their phone numbers.

All persons listed must provide a valid drivers license to pick up a child, No exceptions.

To the best of my knowledge the above information that I have provided is true and complete. I understand that any false information may cause my child to be dismissed from this facility. Any time any of the above numbers change, please make sure that the daycare receives the updated numbers. In the event of any emergency we will need to contact the persons on this list immediately, if we cannot contact the parent or guardian.

I do give / do not give permission for my child To be photographed for media purposes at Kiddie Citie. I understand that if no consent is given, your child will be removed from the classroom during that time.

This consent form will or will not allow Kiddie Citie permission to take your child outside to the playground in back of the daycare, on routine walks around the area, and to the park's in the area.

Note: All other field trips will need further authorization.

No, my child may not go to the park. (Infants not included)