Operation Name:
Director Name:
Child's Full Name:
Child's Date of Birth
MM
DD
YYYY
Child's Phone Number
(###)
###
####
Child's Home Address
Date of Admission
MM
DD
YYYY
Date of Withdrawl
MM
DD
YYYY
Parents or Gardian Name
Address (If different from Child's address)
Mother's Telephone Number
(###)
###
####
Father's Telephone Number
(###)
###
####
Guardian Telephone Number
(###)
###
####
Cell Phone Number
(###)
###
####
Give The Name of A Person in Emergency
Give The Address of A Person in Emergency
Give The Phone number of A Person in Emergency
(###)
###
####
Check All That Apply Transportation
I here by give consent for my child to be transported and supervised by the operation's employee
I here by do not give consent for my child to be transported and supervised by the operation's employee
For Emergency Care
On Field Trip
To & From home
To & From School
Field Trips:
Parent's Comments:
I here by give consent my child to participate in field trip
I here by do not give consent my child to participate in field trip
Water Activities:
My consent for my child to participate in water activities
I hereby give consent
I hereby do not give consent
sprinkler play
splashing/wading pools
swimming pools
water table play
I acknowledge receipt of the facility's operational policies including those for discipline and guidance.
I acknowledge receipt of the facility's operational policies including those for discipline and guidance.
Receipt of Written Operational Policies:
I Understand that the following meals will be served to my child while in care:
None
Breakfast
AM Snake
Lunch
Supper
Evening Snack
My child is normally in care on the following days and times:
Mentioned From Time
To Time
Mondays
Tuesdays
Wednessdays
Thursdays
Fridays
Saturdays
Sundays
Address:
Phone #
(###)
###
####
Name of Emergency Medical Care Facility:
Address
Phone #
(###)
###
####
I give consent for the facility to secure any and all necessary emergency medical care for my child
Signature - Parent or Legal Guardian
List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injiries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver's should be aware of:
Child daycare operations are public accommodations under the Americans with Disablities Act(ADA), Tilte III. If you believe that such an operation may be parcticing discrimination in violation of Tilte III, you may call the ADA Information Line at (800)514-0301 (voice) or (800)514-0383 (TTY).
Signature of Parents
Date
MM
DD
YYYY
School age Children:
My child attands the following school:
Name of School and Address
School Phone Number
(###)
###
####
Check All That Apply:
His/her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.
My Child has permission to walk to and from school
My Child has permission to ride a bus, and/or
My Child has permission to be released to the care of his/her sibling(s) under 18 years old.
Name of Sibling(s):
Immunization Record:
I have provide the childcare operation with a copy of my child's most current immunization record
Admission Requirement: if Your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be presented when your child is admitted to the child-care operation or within one week of admission.
Please check only one option:
Health-Care Professional's Statement: I have examined the above named child within the past year and find that he/she is able to take part in the dat care program.
A Signed and dated copy of a health care professional's statement is attached.
Medical diagnosis and treatment conflict with tenets and practices of a recognized religious organization, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this.
My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and will submit it to the child-care operation.
Health Care Professional's Signature
Date
MM
DD
YYYY
Name and address of health care professional
Signature of Parent or Legal Guardian
Vision
R 20/
L 20/
Vision
Pass
Fail
Signature
Date
MM
DD
YYYY
Hearing
Right Ear
1000 Hz
2000 Hz
4000 Hz
Left Ear
1000 Hz
2000 Hz
4000 Hz
Hearing
Pass
Fail
Signature
Date
MM
DD
YYYY
Signature of Parents or Legal Guardian
Date
MM
DD
YYYY
Health Requirement
Name of Child
Date of Birth
MM
DD
YYYY
Age and Vaccin
Hepatitis B
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Rota Virus
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Dihitheria, Tetanus, Pertussis
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Haemophilus influenzae type b
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Pneumococccal
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Inactivated Polio Virus
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Influenza
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Measles, Mumps, Rubella
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Varicella
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Hepatitus A
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Meningococcal
Birth
1 Mos
2 Mos
4 Mos
6 Mos
12 Mos
15 Mos
18 Mos
19-23 Mos
2-3 Years
4-6 Years
Date
MM
DD
YYYY
TB TEST (if required)
Positive
Negative
Signature or stamp of a physician or public health personnel verifying immunization information above.
Signature
Date 10
MM
DD
YYYY