Fillable Missouri Department of Health - Form DC105 Child Care Enrollment

Fill Online, Printable, Fillable, Blank Missouri Department of Health - Form DC105 Child Care Enrollment Form

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

Missouri Department of Health - Form DC105 Child Care Enrollment

On average this form takes 11 minutes to complete

The Missouri Department of Health - Form DC105 Child Care Enrollment form is 2 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

BROWSE MISSOURI 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
 
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION
CHILD CARE ENROLLMENT FORM FOR LICENSE-EXEMPT FACILITIES
FACILITY/PROVIDER NAME
ADMISSION DATE
DISCHARGE DATE
CHILD’S NAME
GENDER
BIRTHDATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S/GUARDIAN’S NAME
HOME TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
CELL PHONE NUMBER
E-MAIL ADDRESS
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
WORK TELEPHONE NUMBER
HOME TELEPHONE NUMBER
CELL PHONE NUMBER
E-MAIL ADDRESS
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
WORK TELEPHONE NUMBER
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBERS
(CELL, WORK, HOME)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBERS
(CELL, WORK, HOME)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE
ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.
IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL
CARE, I AUTHORIZE
DAY CARE PROVIDER
TO CONTACT THE FOLLOWING:
PHYSICIAN OR CLINIC
NAME
TELEPHONE NUMBER
PREFERRED HOSPITAL
NAME
TELEPHONE NUMBER
MO 580-2124 (8-15) PLEASE ALSO COMPLETE PAGE 2. DC-105 PAGE 1
ACKNOWLEDGEMENTS
A
I HAVE BEEN INFORMED OF THE REQUIRED HEALTH AND SAFETY INSPECTIONS
AND THE INSPECTION FORMS ARE AVAILABLE FOR REVIEW.
PARENT/GUARDIAN INITIALS
B
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE
ACCEPTED FOR CARE OR REMAIN IN CARE.
PARENT/GUARDIAN INITIALS
C
I DO
DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS.
I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED.
PARENT/GUARDIAN INITIALS
D
I DO
DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD.
PARENT/GUARDIAN INITIALS
E
I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR
ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED
IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS
BEEN FILED.
PARENT/GUARDIAN INITIALS
HEALTH REPORT FOR SCHOOL-AGE CHILD
CHILD’S HEALTH HISTORY AND CURRENT HEALTH PROBLEMS
MY CHILD IS IN GOOD HEALTH, IS ABLE TO PARTICIPATE IN GROUP CARE, HAS NO SPECIAL HEALTH OR MEDICAL
REQUIREMENTS.
MY CHILD IS ABLE TO PARTICIPATE IN GROUP CARE BUT HAS SPECIAL HEALTH OR MEDICAL REQUIREMENTS AS
LISTED BELOW.
ANY ALLERGIES, SPECIAL MEDICAL CONDITIONS, INCLUDING CHRONIC HEALTH PROBLEMS
ANY SPECIAL MEDICATIONS AND/ OR RESTRICTIONS
PARENT/GUARDIAN SIGNATURE
DATE
FORM TO BE RETAINED FOR ONE YEAR AFTER DISCHARGE.
FILING: FILE FORM IN CHILD’S INDIVIDUAL RECORD.
MO 580-2124 (11-15) DC-105 PAGE 2
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

Missouri Department of Health - Form DC105 Child Care Enrollment

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 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document