ODFJS Child Enrollment and Health Information (Summer)

This form is required by the Ohio Department of Job and Family Services. Please complete all parts accurately.
CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

SUMMER 2026
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Child’s Full Name*
Date of Birth*

MonthDayYear
Date
Child's Primary Address*

Street Address

CityState / Province

Postal / Zip Code
Telephone Number*
Format: (000) 000-0000.
Child's First Day at Program*

MonthDayYear
Date

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.
Emergency Contact #1 Name*
Relationship to Child*
Telephone Number*
Format: (000) 000-0000.
City*
State*
Other numbers where emergency contact can be reached (if applicable)
Emergency Contact #2 Name
Relationship to Child
Telephone Number
Format: (000) 000-0000.
City
State
Other numbers where emergency contact can be reached (if applicable)

NoYes
If yes, please explain.
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.*
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 special routines, or behavior needs.*

Diapering Statement
Yes - Please skip to next section. (Emergency Transportation Authorization)No - Please complete the remainder of this section.
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 with the program's schedule.
If you do not agree, please complete the statement below:

I would like my child's diaper checked every hours.

Emergency Transportation Authorization
Please complete ONE of the following:

Grant Permission OR Decline Permission

*Do not complete both sections.
Grant Permission
(enter name of daycare) 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.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Decline Permission
(enter name of daycare) 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:
Signature

Clear
Date

MonthDayYear
Date

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE