Ohio Department of Job and Family Services
Child Enrollment and Health Information for Child Care
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Please indicate if this name should be released if a parent/guardian of a child attending the center/home requests contact information for other parents/guardians *
If you answered yes, please indicate which number(s) above to include on the list
If you answered yes, please indicate which number(s) above to include on the list
Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the chold in case the parent/guardian cannot be contacted and should be at least 18 years of age.
Allergies, Special Health or Medical Conditions, and Food Supplements
Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: provide treatment, care, or to give medication, the JFS 01236 "Medical/Physical Care Plan" or equivalent form and/or the JFS 01217 "Request for Administration of Medication" must be completed and be kept on the file at the center or family child care home.
Does your child have any food, medication or environmental allergies? (check all that apply) *
Does your child's allergy/allergies require child care staff to monitor your child for symptoms, take action if a reaction occurs, or give emergency medication to your child? (check one) *
Does your child have a special health or medical condition? (check one) *
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? (check one) *
Is your child currently using and medication, food supplement or medical food (such as electrolyte solution)? (check one) *
If yes, does this medication, food supplement, or medical food need to be administered at the child care center/type A home? *
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) *
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group? *
Diapering Statement
Is your child toilet trained? *
New Hope Preschool and Education Center has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. *
Parent/Guardian Signature *
Acknowledement of Policies and Procedures
I have reviewed and received a copy of the program's or home's policies and procedures/handbook. Check one. *
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care.
Parent/Guardian Signature *
Note: This is a prescribed form which must be used by child care providers to meet the requirements to rules 5101:2-12-15 and 5101:2-13-15. This form must be on file at the program or home on or before the child's first day of attendance and thereafter while the child is enrolled.
JFS 01234 (Rev. 12/2016)
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