* Required Information

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


Give the name, address and phone number of person to call in case of an emergency if parents/guardian cannot be reached.


I hereby authorize the childcare operation to allow my child to leave the children operation ONLY with the following persons. Please list name & telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

Name Phone Number
CHECK ALL THAT APPLY

TRANSPORTATION

FIELD TRIPS

WATER ACTIVITIES

RECEIPT OF WRITTEN OPERATIONAL POLICIES

I acknowledge receipt of the facility's operational policies including those for discipline and guidance


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:


Clear

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.

IMMUNIZATION RECORD.

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.


Clear


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.

Clear

VISION
HEARING


Clear

HEALTH REQUIREMENTS

Signature or stamp of a physician or public health personnel verifying immunization information above

Clear

Clear

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.

Select a country first.