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Child Enrollment and Health Information

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Ohio Department of Job and Family Services

CHILD ENROLLMENT AND HEALTH INFORMATION
FOR CHILD CARE

This form shall be completed prior to the child's first day of attendance and updated annually and as needed.

Parent/Guardian #1: 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.
Parent/Guardian #1: If you answered yes, please indicate which information above to include on the list
Parent/Guardian #1
Parent/Guardian #2: 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.
Parent/Guardian #2: If you answered yes, please indicate which information above to include on the list
Parent/Guardian #2

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
Emergency contact 2
Physician or clinic/hospital
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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/home.

Does your child have any food, medication or environmental allergies? (check all that apply)
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)
Does your child have a developmental delay or special health or medical condition? (check one)
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)
Is your child currently using any medication or medical food? (check one)
If yes, does this medication or medical food need to be administered at the child care program/home?
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one)
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
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Diapering Statement

Is your child toilet trained?

hours. Please indicate if you want your child's diaper checked according to the program's policy or another:

Diaper check schedule hours.

Emergency Transportation Authorization

Give Permission to Transport

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
Give permission to transport

OR. Do not sign both.

Do Not Give Permission to Transport

Parent's Signature
Do not give permission to transport
Acknowledgement of Policies and Procedures. I have reviewed and received a copy of the program's or home's policies and procedures/handbook. (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)
Parent/guardian signature
Administrator/Designee Signature
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.

Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review

Note:

This is a prescribed form which must be used by child care providers to meet the requirements to rules 5101:2-12-15, 5101:2-13-15, and 5101:2-14-04.
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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