Child Enrollment and Health Information

Ohio Department of Job and Family Services

CHILD ENROLLMENT AND HEALTH INFORMATION

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

Fill your details

Child's Name

Date of Birth

First Day at Program/Home

Home Address

City

State

Zip Code

Home Telephone Number

Parent/Guardian Name #1

Relationship to Child

Home Address

Same as Childs

City

State

Zip Code

Home Telephone Number

Same as Childs

Cell Phone Number

Parent's Work/School Name

Parent's Work/School Telephone Number

Parent's Work/School Address

City

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

Same as Childs

City

State

Zip Code

Home Telephone Number

Same as Childs

Cell Phone Number

Parent's Work/School Name

Parent's Work/School Telephone Number

Parent's Work/School Address

City

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?

Name

City

State

City

State

Relationship to Child

Telephone Number

Relationship to Child

Telephone Number

Other numbers where emergency contact can be reached

Name of Physician or Clinic/Hospital

Street Address

City

State

Telephone Number

Does your child have any food, medication or environmental allergies? (check all that apply)

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?

No Yes - a JFS 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?

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?

No Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.

Is your child currently using any medication or medical food?

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 JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication and a JFS 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?

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.

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

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 I agree with the program's schedule ________ hours

Program or Home Name

Parent's Signature

Date

Program or Home Name

Parent's Signature

Date

I have reviewed and received a copy of the program's or home's policies and procedures/handbook.

Yes No

Parent/Guardian Signature(s)

Date

Administrator/Designee Signature

Date

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

The Children’s Place Learning Academy provides a smaller safe and secure environment for children during the most important years of their development.

Enrollments

Contact us

+1 567-289-5212

viviannkids@yahoo.com

2301 Baton Rouge Avenue in Lima, Ohio, 45805

NOW
ENROLLING

Enrollment is open to children from Infant to 12 years of age

Child Enrollment and Health Information