Ohio Department of Job and Family Services: Child Enrollment and Health Information for Child Care 2023-2024

Child's Name *

Date of Birth * +

First Day at Program/Home * +

Home Address *

City *

State *

Zip Code *

Home Phone Number *

Parent/Guardian Name *

Relationship to Child *

Home Address *

Home Phone Number *

City *

State *

Zip Code *

Email Address *

Cell Phone *

Parent's Work/School Telephone Number *

Parent's Work/School Name *

Parent's Work/School Address *

City *

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 *

Yes

No

If you answered yes, please indicate which number(s) 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 *

Relationship to Child *

Home Address *

Home Phone Number *

City *

State *

Zip Code *

Email Address *

Cell Phone *

Parent's Work/School Telephone Number *

Parent's Work/School Name *

Parent's Work/School Address *

City *

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 *

Yes

No

If you answered yes, please indicate which number(s) above to include on the list

Work #

Cell #

Home #

Email

Where can you be reached while your child is in this program/home? *

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 child in case the parent/guardian cannot be contacted and should be at least 18 years of age.

Name *

City *

State *

Telephone Number *

Relationship to Child *

Other numbers where emergency contact can be reached (if applicable)

Name *

City *

State *

Telephone Number *

Relationship to Child *

Other numbers where emergency contact can be reached (if applicable)

Name of Physician or Clinic/Hospital *

Street Address *

City *

State *

Telephone Number *

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) *

Pleas list and explain: *

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) *

No

Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217 "Request for Administration of Medication" must be completed.

Does your child have a special health or medical condition? (check one) *

No

Yes - please explain below

If answered 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? (check one) *

No

Yes - a JFS 01236 "Medical/Physical Care Plan" or equivalent form and if administering medication, a JFS 01217 "Request for Administration of Medication" must be completed.

Is your child currently using and medication, food supplement or medical food (such as electrolyte solution)? (check one) *

No

Yes - please explain

If yes, does this medication, food supplement, or medical food need to be administered at the child care center/type A home? *

No

Yes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication, food supplement or medical food.

N/A - program does not administer any medications.

Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one) *

No

Yes - please explain

If answered 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 the JFS 01217 "Request for Administration of Medication".

N/A - child does not attend a full time program.

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. *

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. *

List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits. *

List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs. *

Diapering Statement

Is your child toilet trained? *

Yes (If yes, skip to Emergency Transportation Authorization section)

No (If no, fill out the following)

Is your child toilet trained? This 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 do not agree, please check my child's diaper every __ hours.

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. *

Yes

No

If no, I wish for the following action to be taken:

Parent/Guardian Signature *

clear

Date * +

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. *

Yes

No

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 *

clear

Date * +

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. 10/2021)