JFS 01234 (Rev. 12/2016) Page 3 of 3
Emergency Transportation Authorization
Give Permission to Transport
Do Not Give Permission to Transport
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
does not have permission to secure emergency
transportation for my child in the event of an illness or injury
which requires emergency treatment. I wish for the following
action to be taken:
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.
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, eating or sleeping habits, or
special routines. This information should not be medical or health related, as that information should be included on the previous
Is your child toilet trained? Yes (If yes, skip to Emergency Transportation Authorization section) No (If no, fill out the
The 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.
Acknowledgement of Policies and Procedures
I have reviewed and received a copy of the program's or home's policies and procedures/handbook. 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.
The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all
information has stayed the same or changes have been noted. If significant changes are needed, please complete a new form.