Fillable Printable Child Care Enrollment Form - Missouri

Child Care Enrollment Form - Missouri

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES

SECTION FOR CHILD CARE REGULATION / BUREAU COMMUNITY FOOD & NUTRITION ASSISTANCE

CHILD CARE ENROLLMENT FORM

MON

TUES

WED

THURS

FRI

SAT

SUN

PLEASE ALSO COMPLETE PAGE 2.

CACFP REQUIREMENT

GENDER

BIRTHDATE

IDENTIFYING INFORMATION

MOTHER'S/GUARDIAN'S NAME

HOME PHONE

AM PM

CELL PHONE

AM PM

WHAT TIME DOES YOUR

CHILD USUALLY ARRIVE

EACH DAY?

CIRCLE AM OR PM.

CHILD'S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

AM PM

ADDRESS (STREET, CITY, STATE, ZIP)

COMMENTS ON CHILD'S DEVELOPMENT

EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP)

WORK PHONE

WHAT TIME DOES YOUR CHILD

USUALLY LEAVE EACH DAY?

CIRCLE AM OR PM.

WRITE ANY COMMENTS, CHANGES OR

VARIATIONS IN USUAL ATTENDANCE IN THIS

SECTION INCLUDING SHIFT CHANGES.

CHECK HERE WHAT DAYS

THE CHILD WILL ATTEND.

WILL CHILD ATTEND:

Full Time or Part Time

AM PM

NAME

WORK/SCHOOL SCHEDULE

AM PM

 YES NO

HOW IS CHILD RELATED TO CHILD CARE PROVIDER?

AM PM

E-MAIL

ADDRESS (STREET, CITY, STATE, ZIP) OR CHECK IF SAME AS ABOVE 

ADDRESS (STREET, CITY, STATE, ZIP)

PHONE NUMBERS

(CELL, WORK, HOME)

EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP)

WORK PHONE

EMPLOYER OR SCHOOL ATTEND

ADDRESS (STREET, CITY, STATE, ZIP)

RELATIONSHIP TO CHILD

HOME PHONE

CHILD'S NAME

(NOTE CHILD'S PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, AND INDVIDUAL NEEDS)

RELATED CHILD

EMPLOYER OR SCHOOL ATTEND

WORK/SCHOOL SCHEDULE

CELL PHONE

PHONE NUMBERS

(CELL, WORK, HOME)

E-MAIL

ADDRESS (STREET, CITY, STATE, ZIP) OR CHECK IF SAME AS ABOVE 

AM PM

DISCHARGE DATE

ADMISSION DATE

FACILITY/PROVIDER NAME

NAME

RELATIONSHIP TO CHILD

EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.

FATHER'S/GUARDIAN'S NAME

MO 580-2994 (1-12) SCCR/CACFP PAGE 1

CACFP REQUIREMENT

PARENT/GUARDIAN INITIALS

CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY

p BREAKFAST p MORNING SNACK p LUNCH p AFTERNOON SNACK p SUPPER p EVE SNACK p NONE

CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY

p NEW YEAR'S DAY

(JANUARY)

p EASTER (MARCH/APRIL)

p MARTIN LUTHER KING JR.'S BIRTHDAY

(JANUARY)

p PRESIDENT'S DAY

(FEBRUARY)

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

p CHRISTMAS DAY

(DECEMBER)

p MEMORIAL DAY (MAY)

p INDEPENDENCE DAY (JULY)

p LABOR DAY (SEPTEMBER)

p COLUMBUS DAY (OCTOBER)

p VETERANS DAY

(NOVEMBER)

p ELECTION DAY (NOVEMBER)

p THANKSGIVING (NOVEMBER)

DAY CARE CENTER OR HOME PROVIDER

TO CONTACT THE FOLLOWING:

PHYSICIAN OR CLINIC

NAME

PHONE

I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGEMENTS FOR MEDICAL

CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.

IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE

___________________________________________________________________________________

PREFERRED HOSPITAL

NAME

PHONE

PARENT/GUARDIAN INITIALS

I p DO

p DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS.

I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED

PARENT/GUARDIAN INITIALS

ACKNOWLEDGEMENTS

THIRD ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

DATE

FIRST ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

I p DO

p DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD

PARENT/GUARDIAN INITIALS

DATE

SECOND ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

PARENT/GUARDIAN INITIALS

DATE

PARENT'S/GUARDIAN'S SIGNATURE

THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING

MY CHILD'S DEVELOPMENT, BEHAVIOR AND INDIVIDUAL NEEDS.

I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE

PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM

IMMUNIZATIONS.

I HAVE RECEIVED A COPY OF THIS FACILITY'S POLICIES PERTAINING TO THE ADMISSION, CARE

AND DISCHARGE OF CHILDREN.

I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OR

THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS

FACILITY FOR REVIEW.

WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR

CARE OR REMAIN IN CARE.

MO 580-2994 (2-11) SCCR/CACFP PAGE 2