Enrollment Packet

General Information
Child's Name*
Child's Date of Birth*

MonthDayYear
Date
Mother Name
Father Name
Address*
Home Phone
Cell Phone*
Email*
example@example.com
Siblings (Names & Ages)
Any Special Food Habits
Any Special Medical Needs
Any Allergies
Any Special Conditions
Has Your Child Previously Attended Child Care*
If Yes Which Center Did They Most Recently Attend
In order to ensure the safety of your child(ren), we would like to know exactly who's picking up your child(ren). Please enter all information:
1. Authorized Pick-Up Name*
Relation*
Phone*
2. Authorized Pick-Up Name
Relation
Phone
3. Authorized Pick-Up Name
Relation
Phone
4. Authorized Pick-Up Name
Relation
Phone
5. Authorized Pick-Up Name
Relation
Phone
6. Authorized Pick-Up Name
Relation
Phone
Our staff will be authorized to request photo ID from everyone on the pick up list. The ID will be photocopied and placed in the child's folder.
I authorize the people I've Listed above to pick-up my child(ren). (Type Parent/Guardian Name)*
ParentGuardian Signature*

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MonthDayYear
Date
CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE
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.
Childs Name*
Date of Birth*

MonthDayYear
Date
Potential First Day at Program *
Home Address*
City*
State*
Zip Code*
Contact Telephone Number*
Parent/Guardian Name 1*
Relationship to Child*
City*
State*
Zip*
Email Address*
example@example.com
Cell Phone
Parents Work or School Name*
Parent's Work or School Telephone Number*
Please enter a valid phone number.
Parents Work or School Address*
City*
Please indicate if this name should be released if a parent/guardian, of a child attending the program requests contact information for other parents/guardians.

YesNo
If you answered yes, please indicate which information above to include on the list:

Work NumberCell NumberHome NumberEmail
Where can you be reached while your child is in this program?*
Parent Guardian Name #2
Relationship to Child
Home Address
Home Telephone Number
City
State
Zip
Email Address
example@example.com
Parent's Work/School Telephone Number #2
Parents Work/School Name #2
Parent's Work/School Telephone Number #2
Please enter a valid phone number.
Parents Work/School Address #2
City
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 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*
City*
State*
Telephone Number*
Relationship to Child*
Other numbers where emergency contact can be reached (if applicable)
Emergency Contact #2
City
State
Telephone Number
Relationship to Child
Other numbers where emergency contact 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.
Does your child have any food, medication or environmental allergies? (check all that apply)*

NoYes - check all that applyFoodMedicationEnvironmental
If yes please 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)*

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 (Check One)*

NoYes
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? (check one)*

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? (check one)*

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

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 reason? (Check one)*

NoYes
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.
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. Type "NA" if 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. Type "NA" if Not Applicable.*
List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits. Type "NA" if Not Applicable.*
List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs. Type "NA" if Not Applicable.*
Is your child toilet trained?*

YesNo
If No, our program policy is to check diapers every 2 hours. Please indicate how often would you like you child diaper to be check/changed?
EMERGENCY TRANSPORTATION AUTHORIZATION
By signing ONE option below, please indicate with your signature (PLEASE ONLY SIGN YES OR NO) If Carnival has permission to secure emergency transportation for your child in the event of an illness or injury which requires emergency treatment:
YES, Carnival has permission to secure emergency transportation (Sign Below)

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Date
NO, Carnival does not have permission to secure emegency transportation for my child (Sign Below)

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MonthDayYear
Date
If No, please indicate the following actions you would like us to take in case of a emergency?
Acknowledgement of Policies and Procedures
Our policies and procedures is listed on our websites at www.carnivalcdc.org on our parent resource tab. Please check the box below acknowledging you have access to view our parent handbook at any time*

Yes - I was made aware of where to find our parent handbook
Parent Handbook Acknowledgement

I, the undersigned, acknowledge that I have unlimited access to the Parent Handbook for Carnival Child Development Center on their website www.carnivalcdc.org on the parent resource tab and agree to all the terms, conditions, and policies of CCDC. I recognize that it is my responsibility to read and understand the policies, provisions, and procedures contained in the Parent Handbook

In addition, I understand that the contents of the Parent Handbook are subject to change. I acknowledge that the Parent Handbook will be revised in accordance with the rules or regulations of state, federal, and accrediting entities, best practices for child care service providers, or at the discretion of Carnival Child Development Center. I recognize that any such revisions will supersede, modify, or eliminate the current contents of the Parent Handbook. I acknowledge that it is my responsibility to stay informed of policy and procedure revisions to the Parent Handbook, which will be posted on Carnival Child Development Center web site at www.carnivalcdc.org under the parent resource tab. In the event I do not have internet access, I understand that I can obtain a hard copy of the updated Parent Handbook upon request to Carnival Child Development Center. Moreover, I recognize that it is my responsibility to contact Carnival Child Development Center Director for any questions I might have about the contents of the Parent Handbook now and in

We have a 10:00am cut off time

Breakfast is cut off at 9:00am sharp. Lunch is served at 11:00am No outside toys allowed (unless for a scheduled show-and-tell day) No outside food is allowed in the center (unless authorized by the office for birthdays or special occasions) We're closed all major holidays; you will receive a memo before we're closed. We now require a holding fee of $100/weekly for extended absences longer than one
ParentGuardian Signature

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Date
ROUTINE WALKS PERMISSION FOR CHILD CARE
Routine walks to the playground and around the building
Date of Permission valid for one year

MonthDayYear
Date
My child is:

not over 4 years and/or 40 lbsover 4 years and 40 lbs8 years and/or over 4'9"
Parents Signature

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Date
These next set of questions are for INFANTS ONLY. If your child is not a infant please skip to the FAMILY NEEDS SURVEY
BASIC INFANT INFORMATION FOR CHILD CARE
Child's Name
Nickname
Childs Date of Birth

MonthDayYear
Date
Siblings
What are you feeding your infant (check all that apply)

FormulaBreast Milk
Formula preparation (if center is to prepare)
Amount for each feeding
Frequency of feedings
My infant likes a bottle warmed (Check One)

Room TempWarmVery Warm (not hot)
Juice (type, amount, when)?
Does child use a cup yet?

NoYes
Are foods served room temperature or warmed
Table food (types, amounts, frequency, special instruction)
Security items (pacifier, blankets, etc.)
Nap schedule
Hints for getting baby to sleep
Sleeping position

BackSideTummy
Special Precautions
Any additional information about your child that would be helpful or you would like staff to know
Parent Signature

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Date
FAMILY NEEDS SURVEY
We want to support any needs you or your family may have. This information you provide on this form is confidential. Please select Yes or No to best describe your current situation. Our goal is to provide resources to support you and your family based on your answers.

Child Development & Education - Does anyone in your family have any need for resources or support in the areas listed below?*

	Yes	No
Information on child growth & development
Guiding & supporting a child's behavior
Medical or disabilities or possible conditions for any child or adult in the family
Obtaining toys or activities to use to help any child in your home
Preparing your child for kinderrgarten

Child & Family Health - Does anyone in your family have any need for resources or support in the areas listed below?*

	Yes	No
Health insurance and/or access to regular medical care, dental care, or medications?
Medical or health supplies or supports that anyone in your family needs?
Accessing immunizations?
Finding a pediatrician, general practitioner, dentist, therapist, psychologist, optometrist, or other specialty practitioner.

	Yes	No
Any concerns with depression, anger, anxiety, or mental health needs?
Any concerns with alcohol, drug, or addiction problems?

Financial and household supports - Does anyone in your family have any need for resources or support in the areas listed below?*

	Yes	No
Help paying for child care
Help finding housing or safe housing
Help paying your mortgage or rent
Help with food expenses

	Yes	No
Help with finding household items such as furniture, clothing, or school supplies
Help with access to transportation or transportation expenses
Help attending school (such as a GED, Certifications, or college degrees)
Help finding work or job training

Are there other needs you or your family have that are not listed above?
CHILD AND ADULT CARE FOOD PROGRAM

Enrollment Form
Form required for us to serve meals
CHILDS NAME *
AGE*
CHILD BIRTHDATE
Month*
Day*
Year*

Tentative Schedule*

	Arrive	Depart
Monday
Tuesday
Wednesday
Thursday
Friday

Check this box if schedule may vary
PARENT BIRTHDATE
MONTH*
DAY*
YEAR*
INCOME ELIGIBILITY APPLICATION FOR FREE AND REDUCED-PRICE MEALS (ALL PARENTS ARE REQUIRED TO FILL OUT THIS FORM)

NAME OF ENROLLED CHILD(REN)*

	Name Of All Children Enrolled	Age	Birthdate
1.
2.
3.
4.

If you have a 7 Digit Ohio Benefit Case Number enter it below:

If no 7 digit case number is listed above, PLEASE complete total household income below

	List Names of all Household members including children	Estimated Income $	How Often received(Weekly, Monthly, or Annually)
1.
2.
3.
4.
5.
6.

Last 4 Digits of Parent/Guardian Social Security Number:*
Racial/Ethnic Identity: Please check appropriate box to identify the race of enrolled children (Check all that apply)*

American Indian or Alaska NaticeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherHispanic or LatinoNot Hispanic or Latino
Should be Empty:

General Information

CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

EMERGENCY TRANSPORTATION AUTHORIZATION

Acknowledgement of Policies and Procedures

ROUTINE WALKS PERMISSION FOR CHILD CARE

These next set of questions are for INFANTS ONLY. If your child is not a infant please skip to the FAMILY NEEDS SURVEY

BASIC INFANT INFORMATION FOR CHILD CARE

FAMILY NEEDS SURVEY

CHILD AND ADULT CARE FOOD PROGRAM

CHILD BIRTHDATE

PARENT BIRTHDATE

INCOME ELIGIBILITY APPLICATION FOR FREE AND REDUCED-PRICE MEALS (ALL PARENTS ARE REQUIRED TO FILL OUT THIS FORM)