Ohio Department of Children and YouthCHILD ENROLLMENT AND HEALTH INFORMATIONFOR 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
-
Month
-
Day
Year
Date
First Day at Program/Home
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone Number
Format: (000) 000-0000.
Parent/Guardian Name #1
Relationship to Child
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone Number
Format: (000) 000-0000.
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address (if applicable)
example@example.com
Same as Child's
Cell Phone (if applicable)
Format: (000) 000-0000.
Parent's Work/School Name
Parent's Work/School Telephone Number
Format: (000) 000-0000.
Parent's Work/School Address
Street Address
Street Address Line 2
City
State / 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.
Yes
No
If you answered yes, please indicate which information above to include on the list
Work #
Cell #
Home #
Email
Where can you be reached while your child is in this program/home?
Parent/Guardian Name #2
Relationship to Child
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Same as Child's
Home Telephone Number
Format: (000) 000-0000.
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Same as Child's
Email Address (if applicable)
example@example.com
Cell Phone
Format: (000) 000-0000.
Parent's Work/School Name
Parent's Work/School Telephone Number
Format: (000) 000-0000.
Parent's Work/School Address
Street Address
Street Address Line 2
City
State / 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.
Yes
No
If you answered yes, please indicate which information above to include on the list
Work #
Cell #
Home #
Email
Where can you be reached while your child is in this program/home?
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.
Name
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
Format: (000) 000-0000.
Other numbers where emergency contact can be reached (if applicable)
Name
Relationship to Child
Telephone Number
Format: (000) 000-0000.
Relationship to Child
Other numbers where emergency contact can be reached (if applicable)
Name of Physician or Clinic/Hospital
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
Format: (000) 000-0000.
DCY 01234 (Rev. 8/2025)
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Child's Name
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 DCY 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
Yes - check all that apply
Food
Medication
Environmental
Please list and 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)
No
Yes - a DCY 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
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)
No
Yes - a DCY 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
Yes - please explain
If yes, does this medication or medical food need to be administered at the child care program/home?
No
Yes - a DCY 01217 "Request for Administration of Medication" must be completed and kept on file for each medication and a DCY 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? (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.
DCY 01234 (Rev. 8/2025)
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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.
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.
Not applicable
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Child's Name
Diapering Statement- 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 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 hours
Emergency Transportation Authorization
Give Permission to Transport
Program or Home Name
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's Signature
Date
-
Month
-
Day
Year
Date
Parent's Signature
Date
-
Month
-
Day
Year
Date
Acknowledgement of Policies and Procedures
Yes
No (check one)
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.
Parent/Guardian Signature(s)
Date
-
Month
-
Day
Year
Date
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.
Note: This is a prescribed form which must be used by child care providers to meet the requirements to rules 5180:2-12-15, 5180:2-13-15, and 5180:2-14-04. This form must 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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