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.
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.
Diapering Statement
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.
OR "Do Not Sign Both"
Do Not Give Permission to Transport
does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. I wish for the following action to be taken:
Acknowledgement of Policies and Procedures
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.
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 5101:2-12-15, 5101:2-13-15, and 5101:2-14-04. This formmust 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.
