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Application form
Main Application Form
Child's Name
Date of birth
first day at center
Home Address
zip code
Home Telephone number
parent/guardian Name
relationship of child
Home Address
Home telephone number
city
state
Zip
Email Address (if applicable)
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 parent/guardian.
yes
no
if you answered yes, please indicate which number(s) above to include on the list
works #
cell #
home #
Email
where can you be reached while your child is in this program?
Child's Name
Date of birth
first day at center
Home Address
zip code
Home Telephone number
parent/guardian Name
relationship of child
Home Address
Home telephone number
city
state
Zip
Email Address (if applicable)
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 parent/guardian.
yes
no
if you answered yes, please indicate which number(s) above to include on the list
works #
cell #
home #
Email
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
Home
state
city
relationship to child
Telephone number
other numbers where emergency contact can be reached (if applicable)
Home
city
state
Telephone number
relationship to child
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 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
Dose 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 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 mediacation a, JFS 01217 "Request For Administration Mediacation" must be completed
Does your child's have a special health or medical condition? (Ceck One)
No
yes (please)
Does the Special health or medical condition require child care staff to monitor 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 mediacation a, JFS 01217 "Request For Administration Mediacation" must be completed
Is your currently using any medication, food supplement or medical food such as (electrolyte solution)? (check one)
No
yes (Please)
Does your child have any dietary restrictions, including those for medical,religious or cultural reason?(check one)
No
Yes - please explain
does this dietary restriction require a modified diet that eliminates all type of fluid milk or an entire food group?
No
yes - written instruction form the child's health care provider must be on the JFS 01217 "request for administration of medication"
N/A-child 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, 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
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 center/type A home's policy or another:
I agree with the program's schedule
I do not agree, please check my child's diaper every hours
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
Date
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
Date
A acknowledgement of policies and procedures
Untitled
Yes
No
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)
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 pleases 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
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
I give permission for my child to walk within a 3 mile radius with little Generation Day care
signature
Date
swimming of water activities permission slip
I give permission for my child
child's Name
Date of birth
To participate in water activities at little Generation Day care
My child's is a:swimming
Non-swimming
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
signature
Date
Note** parents, the swimming pools are wading pools!!!
promotional photos
I give permission for my child to be included in program evaluations, press interview, and promotional picture
Yes, included my child
No, do not publish
signature
Date
Note** Some pictures may be posted on facebook or on aur website.
permission for screening
I (parent's name) give permission for my child:
(child's name) to receive routine development screening through little generation Day care and/or Toledos county head start for the sole purpose of ruling out any possible developmental delays.<br><br><br> Any concerns will be brought directly to the parent/guardian's attention and a plan put in place to help improve the area of possible deficiency.
parent/Guardian signature:
Date:
child Release Authorization
My child is permitted to go with the following persons.
parent/Guardian signature
Date
Child Name:
DOB:
Site:
PARENT/guardian:
Address:
Phone:
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.
Current medication:
Allergies:
required screening
ohio Epsdt requires all screenings
HT:
WT;
BP:
HGB/HCT
HEARING: R
L
VISION: R
L
LEAD LEVEL
UNDER TREATMENT FOR
SEIZURES
HEART CONDITION/DISEASE
ASTHMA
ECZEMA
EMOTIONAL/BEHAVIOR
DIABETES
LEAD POISONING
OTHER:
ABNORMAL FINDINGS & PLAN:
DIETARY RESTRICTIONS:
NECESSARY SUBSTITUTIONS:
ADDITIONAL COMMENTS:
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.
PHYSICIAN SIGNATURE AND DATE:
PRINTED PHYSICIAN NAME:
ADDRESS
Phone:
EXAM DATE:
ohio Department of job and family services
CHILD CARE PLANE OF HEALTH CONDITION OR MEDICAL PROCEDURES
FOR CHILD CARE CENTER AND TYPE A HOMES
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.
Child's Name
Date of Birth
Describe the heath condition.
Describe the medical procedure to be completed and expected benefits treatment, or N/A,no medical procedure required
last activities/foods/environmental conditions to avoid or N/A, nothing to avoid.
symptoms to watch for and actions to be taken if the symptoms are observed.
Is any medication required?
Yes
No
(If yes,complete FJS 01217 'Request for administration of medication'. in addition to this form. )
In emergency does this child require additional assistance (more than other children of the same age or in the same group ) to evanescent if yes, pleases describe:
Yes
No
signature of trainer (trainer must be parent/Guardian or certified professional )
Date
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.
parent's signature
Date
Administrator's signature
Date
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)
Scanned to CP:
CHILD NAME:
DOB:
SITE:
PARENT/GUARDIAN:
ADDRESS
A dental examination is mandatory for every child entering a lucas county head start collaborative center.
Phone
DENTAL EXAM VISIT:
EXAM DATE
RECEIVED:
Only Exam
Prophylaxis
Fluoride
X-rays
According to services rendered as of the date above ,the following has been determined:
NO Restorations needed at this time. Next six-month check-up is
Needs restorations, extractions, etc. but not begun at this visit.
Treatment plan:
Number of teeth that need treatment*:
Number of visits needed:
Our office referred child to:
TREATMENT VISIT(S):
DATES:
Some restorations, crowns, extractions,treatment received but not all necessary treatment complete.
Number of teeth still needing treatment*:
Number of teeth still needing treatment*:
scheduled appointment date(s)/time(s):
All restorative treatment complete at this visit.
*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.
DENTIST SIGNATURE:
PRINT DENTIST NAME:
ADDRESS:
DATE:
PHONE:
CENTER NAME
CHILD'S NAME
AGE
BIRTHDATE
SIGNATURE OF PARENT/GUARDIAN
DATE
DAY PHONE NUMBER
MAILING ADDRESS: STREET /APT.
CITY
ZIP CODE
child's Name (last)
First
Nickname (if any)
Who is the child's immediate family?
Who lives at homes with your child?
what is the primary language spoken in your child's home?
Are there any special family arrangement, such as shared parenting, living in two homes, or custody specifications, etc? Addition detail?
Are there any changes or transitions that your child has recently experienced or is experiencing ?(moved from crib to bed, divorce new homes, death of family member, friend or pet) Additional detail?
Are there cultural or religious practices of your family we should be aware of?(Dietary restrictions, clothing, head coverings, etc)
Do you have any pets at homes? if so, what are they and what are their names?
Has your child had a previous care arrangement?Additional Detail? (Center based, in home,with family with parents, etc. )
Yes
No
My child drinks (check all the apply) How much and how often?
milk
formula
juice or
water
Does your child have any favorite foods?
Does your child dislike any foods?
Are there any foods your child should not be fed? (licencing requires documentation be completed for children with food allergies and/or dietary restrictions)
please check all of the words that best describe your child's personality and behavior
active
adventurous
affectionate
anxious
bossy
bright
busy
calm
cautious
cheerful
content
creative
curious
easily-angered
emotional
energetic
excitable
friendly
gives-in-easily
happy
hesitant
quiet
sensitive
serious
shares-well
social
spontaneous
stubborn
tentative
other
Are there additional personality and behavior characteristics that would be useful to know about your child?
Are there things that fright your child? if so, how does he/she react and what do you do you do to comfort him/her?
what routines/actions or item do you use to comfort your child?
what causes your child to feel angry or frustrated?
what methods do you use to respond to your child's negative behavior?
Does your child use any special comfort or support items that help him/her go to sleep? if so,that?
what is your child's mood upon walking? (happy,grouchy,show to awaken)?
My child sits in a .(check the one that applies.)
high chair
booster
child size chair
adult size chair
Is your child toilet trained? if not, have you started the toilet training process? please explain the process used .
Does your child need assistance when using the toilet? if so, how?
what words, gestures or signs does your child use if he/she needs to use the bathroom?
what time does your child normally go to bed at night and wake up in the moring?
Does you child have trouble sleeping (night terrors, trouble going to sleep, etc )? please explain.
What might you and/or your child be anxious about as he/she starts in this program?
What are you ans/or your child excited about as he/she starts in this program?
What are your exportation of this program?
What other information would be helpful for the staff caring for your child to know?