Family Child Care Enrollment Packet Face Sheet (Page 3 of 8) in pdf

Family Child Care Enrollment Packet Face Sheet Page 3

Written Acknowledgement of Receipt of Parent Handbook

I acknowledge that I have received a copy of the provider’s parent handbook as well as information

regarding lead poisoning prevention (may be included in the parent handbook).

_______________________________________________

______________

Parent/Guardian

Date

Parental Visit Notice

I understand that I may visit this family child care home unannounced at any time during the hours that

my child is in care.

______________________________________________

_______________

Parent/Guardian

Date

Child's Physician or Health Care Professional

Name: ______________________________________________ Telephone: ___________________

Address: ___________________________________________

Information on allergies, special diets, chronic health conditions, special limitations, concerns including

medications child is taking at home/school and possible side effects:

____________________________________________________________________________________

Medical Insurance Information (OPTIONAL)

Subscriber's Name: _________________________________ Policy #: _____________________

Type of Insurance: _________________________________

[ ] Copy of Insurance Card

SCHOOL AGE ONLY

Current School: ____________________________

School Address: _________________________

______________________________________

I certify that documentation of physical examination and immunizations in accordance with public school

health requirements, and lead poisoning screening in accordance with public health requirements are on

file at my child’s school.

Parent/Guardian initials: ________________

Child’s Name ______________________

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FCCEnrollmentPacket20110406

Family Child Care Enrollment Packet Face Sheet Page 3