* = Required Information
List telephone numbers below where parents/guardian may be reached while child will be in care:

CHECK ALL THAT APPLY
TRANSPORTATION
Give Do not give
for emergency care
on field trips
to and from home
to and from home school
FIELD TRIPS
Give Do not give
WATER ACTIVITIES
Give Do not give
sprinkler play
splashing/wading pools
swimming pools
water table play
RECEIPT OF WRITTEN OPERATIONAL POLICIES
I acknowledge receipt of the facility's operational policies including those for discipline and guidance
I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:
None Breakfast
AM Snack Lunch
PM Snack Supper
Evening Snack
MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to toke my child to:

SCHOOL AGE CHILDREN
My child attends the following school:
CHECK ALL THAT APPLY
His/her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.
ride a bus, and/or
walk to or from school or home,
be released to the care of his/her sibling(s) under 18 years old.

I have provided the childcare operation with a copy of my child's most current immunization record

ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be presented when your child is admitted to the child-care operation or within one week of admission.

Please check only one option:
HEALTHCARE PROFESSIONAL'S STATEMENT: I have examined the above named child within the past year and find that he / she is able to take part in the day care program.
A signed and dated copy of a health care professional's statement is attached
Medical diagnosis and treatment with the tenets and practices of a recognized religious organization, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this
My child has been examined within the past year by a health care professional and is able to participate in the day care program. Within 12 months of admission, I will obtain a health care professional's signed statement and will submit it to the child-care operation.

VISION
Pass Fail
HEARING
1000 Hz
2000 Hz
4000 Hz
Pass Fail
HEALTH REQUIREMENTS
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Birth 1 mos
2 mos 4 mos
6 mos 12 mos
15 mos 18 mos
19-23 mos 2-3 Yrs
4-6 Yrs
Positive Negative
Signature or stamp of a physician or public health personnel verifying immunization information above
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.
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