CHILD'S PREADMISSION RECORD
This section is to be completed by the child's parent or guardian. This form must be kept in the child's file in the Child Care Facility (home/center).
Child's Name:
Name child is known by:
Child's birthdate:
Child's home address:
Name(s) of parent(s)/guardian(s):
Home telephone number:
Format: (000) 000-0000.
Address of parent(s)/guardian(s):
Mother's Employer:
Father's Employer:
Mother's Email Address:
example@example.com
Father's Email Address:
example@example.com
Employer's address:
Employer's address:
Employer's Telephone Number:
Format: (000) 000-0000.
Employer's Telephone Number:
Format: (000) 000-0000.
List telephone numbers such as pager, cellular phone, etc.
Instructions regarding how parent/guardian may be reached in an emergency:
Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached:
Rows
Name
Relationship to child
Address
Telephone number
1
2
3
Name of child's doctor:
Address:
Telephone number:
Format: (000) 000-0000.
Emergency Authorization:
I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)
Signature
Date
-
Month
-
Day
Year
Date
Form not valid without signature of child's parent/guardian
Page one of two-form not valid without second page
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Child's Preadmission Record (continued) - page two of two - form not valid without first page
Describe any special needs or instructions below:
Person(s) the child may be released to:
Rows
Name
Relationship to child
Address
Telephone number
1
2
3
4
5
I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licensee of the child care facility assumes full responsibility for such activities.
Signature of parent/guardian
Date
-
Month
-
Day
Year
Date
I give permission for my child to participate in:
(Circle yes or no and sign each line)
Activities away from the facility:
yes
no
Signature of parent/guardian
Date
Transportation provided by the facility:
yes
no
Signature of parent/guardian
Date
Swimming/wading activities provided by the facility:
yes
no
Signature of parent/guardian
Date
Form not valid without signature of child's parent/guardian in each space indicated above.
This section is to be completed by the facility's staff.
Child's first day of attendance:
Child's withdrawal date:
This child meets the definition of homelessness according to the McKinney-Vento Homeless Assistance Act.
Additional information may be attached.
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H. Authorization for administering medication
DHR-CDC-1949
AUTHORIZATION FOR ADMINISTERING MEDICATION/MEDICAL PROCEDURES
Dear Parent/guardian,
Your written permission is required to administer medication or medical procedures to your child. Any prescription drug or over-the-counter drug sent to the child care facility (home or center) must be in its original container and must be clearly labeled with your child's name, the name of the drug, and directions for administering the drug. A new authorization form is needed each week. If it is absolutely necessary for your child to be given medication while at the child care facility, please complete the following information.
Child's Name
Prescription Number
Name of Medication
Amount of medication to be given at each dosage
Instructions (how to give or apply, such as given by mouth, apply to skin, inhale, drops in eyes, etc.)
Time and date of last dosage given at home
Time(s) of dosage(s) to be given at the child care facility
Please give my child the above-named medication at the time(s) and in the amount(s) indicated.
Signature of parent/guardian
Date
-
Month
-
Day
Year
Date
To be completed by licensee/staff/caregiver
Rows
Date medication given
Time medication given
Signature of person giving medication
1
2
3
4
5
6
7
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