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Child Enrollment and Health Information
Food Enrollment Form
Child Medical Statement Form
Permission to Photograph
Calendar
Careers
Contact us
Welcome
About Us
Enrollment
Tuition Fee
Infant Info
About Your Child Enrollment
Routine Trip Enrollment
Child Enrollment and Health Information
Food Enrollment Form
Child Medical Statement Form
Permission to Photograph
Calendar
Careers
Contact us
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.
Download CEHI Form
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
Email
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
Email
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
Name
City
State
City
State
Relationship to Child
Telephone Number
Relationship to Child
Telephone Number
Other numbers where emergency contact can be reached
Other numbers where emergency contact can be reached
Name of Physician or Clinic/Hospital
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)
No
Yes - check all that apply
Food
Medication
Environmental
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
Submit Details
NOW
ENROLLING
Enrollment is open to children from Infant to 12 years of age
Now Enrolling
