Fillable FOR CHILD CARE CHILD ENROLLMENT AND HEALTH INFORMATION (Owens Community College)

Fill Online, Printable, Fillable, Blank FOR CHILD CARE CHILD ENROLLMENT AND HEALTH INFORMATION (Owens Community College) Form

Use Fill to complete blank online OWENS COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FOR CHILD CARE CHILD ENROLLMENT AND HEALTH INFORMATION (Owens Community College)

On average this form takes 25 minutes to complete

The FOR CHILD CARE CHILD ENROLLMENT AND HEALTH INFORMATION (Owens Community College) form is 3 pages long and contains:

  • 0 signatures
  • 33 check-boxes
  • 85 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Owens Community College

BROWSE OWENS COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Ohio Department of Job and Family Services
CHILD ENROLLMENT AND HEALTH INFORMATION
FOR CHILD CARE
JFS 01234 (Rev. 12/2016) Page 1 of 3
This form shall be completed prior to the child's first day of attendance and updated annually and as needed.
Child’s Name
Date of Birth
First Day at Program/Home
Home Address
City
State
Zip Code
Home Telephone Number
Parent/Guardian Name
Home Address
City
State
Zip
Email Address (if applicable)
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
Home Address
City
State
Zip
Email Address (if applicable)
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
Name
City
State
City
State
Telephone Number
Relationship to Child
Telephone Number
Relationship to Child
Other numbers where emergency contact can be reached (if
applicable)
Other numbers where emergency contact can be reached (if
applicable)
Name of Physician or Clinic/Hospital
Street Address
City
State
Telephone Number
Reset Form
JFS 01234 (Rev. 12/2016) Page 2 of 3
Child’s Name
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: to monitor the condition, 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 file at the center or family child care home.
Does your child have any food, medication or environmental allergies? (check all that apply)
No
Yes - check all that apply Food Medication Environmental Please 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
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 any 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
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.
JFS 01234 (Rev. 12/2016) Page 3 of 3
Emergency Transportation Authorization
Give Permission to Transport
OR
Do
not
sign
both
Do Not Give Permission to Transport
Program or Home Name
Program or Home Name
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.
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:
Parent's Signature
Date
Parent's Signature
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.
Child's Name
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
page.
Diapering Statement
Is your child toilet trained? Yes (If yes, skip to Emergency Transportation Authorization section) No (If no, fill out the
following)
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
(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(s)
Date
Administrator/Designee Signature
Date
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.
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Parent/Guardian Initials
Date of Review
Administrator/Designee Initials
Date of Review
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FOR CHILD CARE CHILD ENROLLMENT AND HEALTH INFORMATION (Owens Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document