Application form

Main Application Form

  • where can you be reached while your child is in this program?
  • where can you be reached while your child is in this program?
  • Emergency contact: parents cannot be listed as emergency contact. list the name of at elated 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 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 year of age
  • Allergies, special health or medical conditions, and food supplements

    fill in this section 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 "must be completed and be kept on file at the center or type A home
  • 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 health related, as that information should be included on the previous page.
  • diapering statement
  • Emergency transportation Authorization
    Give permission to transport center or type A Home Name has permission to secure emergency transportation of my child in to event of an illness or injury which requires emergency treatment.The emergency transportation service will be transported.
    parent's signature
  • OR Do not sign both
  • Emergency transportation Authorization
    Do not give permission to transport center or type A Home Name 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
  • A acknowledgement of policies and procedures
    I have reviewed and received a copy of the center's or type A home's policies and procedures/handbook.
  • 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.After the child is attending the program the administrator shall have the parent/guardian review and initial the form when any changes.updates are made and at least annually. the parent/guardian and the administrator or designee shall initial and date the form in the section below to indicate when the form was last reviewed.
  • parent/Guardian signature(s)
  • Administrator/Designee signature
  • 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 pleases complete a new form.
  • Note:This is a prescribed form which must be used by center and type A homes to meet the requirement of rules 5101:2- 13-37. This form must be no file at the center or type A home on or before the child's first day of attendance and thereafter while the child is enrolled
    JFS 01234 (Rev. 9/2011)
  • Routine walk permission slip
  • swimming of water activities permission slip
  • To participate in water activities at little Generation Day care
  • The state licensing staff/child ratio for this group is: 12 pre-k 14 pre-k 15 SA
    we will have additional child care staff members above the licensing ratio requirement
  • Note** parents, the swimming pools are wading pools!!!
  • promotional photos
  • Note** Some pictures may be posted on facebook or on aur website.
  • permission for screening
  • child Release Authorization
  • A physical examination and shot records are mandatory for every child entering a preschool program or pre-k childcare program in the state of ohio.
  • required screening
    ohio Epsdt requires all screenings
  • This is to certify that i have examined this child and found that:
    1.This child has had the immunizations recommended by the CDC according to the child's age or is to be exempted from these requirement for a medical reason. (please note exemption)
    2.ANTICIPATORY GUIDANCE has been provided to parent through discussion or handouts and medical/family/social history is reviewed at each well child Examination.
    3. Based upon medical history ans physical condition at the time of this examination, this child is in suitable condition to participate in the group care.
  • ohio Department of job and family services
  • If care provided for a child who has an ongoing health condition that requires child specific care or many require a medical procedure, the parent/guardian shall complete this form.The center staff shall implement the plan.This requirement does not include short term illnesses, unless the child care staff member needs to perform a medical procedure for the child. A separate plan must be written for each condition that require different actions to be taken.
  • symptoms to watch for and actions to be taken if the symptoms are observed.
    (If yes,complete FJS 01217 'Request for administration of medication'. in addition to this form. )
  • signature of trainer (trainer must be parent/Guardian or certified professional )
  • signature of child care staff members who have been informed about the child's condition so they can care for the child according to this care plan or trained perform the medical procedure .
    There must always be a trained staff member present when the child is present
  • I give my permission for the staff listed above to perform the procedures in my child's care plan as described above.
  • This form may be used for children with health conditions as defined rules 5101: 2-12-38 and 5101:2-12-38.
    JFS 01236 (REV.9/2011)
  • A dental examination is mandatory for every child entering a lucas county head start collaborative center.
  • According to services rendered as of the date above ,the following has been determined:
  • Treatment plan:
  • *Note: Head start family support partners will use the number of teeth needing service and appointment information to assist parent to the importance of receiving treatment.