Child Enrollment And Health Information
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Ohio Department of Job and Family Services
CHILD ENROLLMENT AND HEALTH INFORMATION
FOR TYPE B FAMILY CHILD CARE AND IN-HOME AIDES
Child’s Name
Date of Birth
Date form completed/updated
First Day in Care
Home Address
City
Names of additional children in the family
in care
State
Zip Code
Home Telephone Number
Parent/Guardian Name
Relationship to child
Home Address
City
State
Zip
Home Telephone Number
Cell Phone
Employer/School/Training
Work/School/Training Telephone Number
Address
City
Pager and directions for use
Where can you be reached while your child is in this program?
Parent/Guardian Name
Relationship to child
Home Address
City
State
Zip
Home Telephone Number
Cell Phone
Employer/School/Training
Work/School/Training Telephone Number
Address
City
Pager and directions for use
Where can you be reached while your child is in this program?
Emergency Contacts: List the names of two local persons who you want to be contacted in the event of an emergency or illness if the parent/
guardian cannot be reached. Persons listed should be able to assist in locating the parent/ guardian and at least one person listed must be able to take
responsibility for the child in cases where the parent/ guardian can not be located. Parents cannot be listed as emergency contacts.
Name
Name
State
City
City
State
Telephone Number
Relationship to Child
Telephone Number
Relationship to Child
Other numbers where emergency contact can be reached (optional)
Other numbers where emergency contact can be reached (optional)
Name of Child's Physician or Clinic/Hospital
Name of Child's Dentist or Clinic
Street Address
Street Address
City
State
Telephone Number
City
State
Telephone Number
Note: This is a prescribed form provided by JFS which must be used by Type B homes and in-home aides to meet the requirements of chapter
5101:2-14. This form must be completed and on file at the Type B home or with the in-home aide on or before the child’s first day of attendance.
JFS 01297 (Rev. 8/2008)
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