Child Enrollment And Authorization

ADVERTISEMENT

Child Enrollment and Authorization
Child’s Last Name
Date Entered Care
___________________________________________________________________________________________________
Child’s First Name
Age at Entry to Care
___________________________________________________________________________________________________
Child’s Nickname
Date of Birth
:
ALLERGY ALERT
Does child have allergies?
Yes
No
If yes, list all allergies on back side of form
Parent or Guardian Contact Information
Name (first, last)
Relationship
Home Address
City
Zip
Home Phone
Work Phone
Employer and Work Hours
Cell Phone
Work Address
City
Zip
Name (first, last)
Relationship
Home Address
City
Zip
Home Phone
Work Phone
Employer and Work Hours
Cell Phone
Work Address
City
Zip
Required Emergency Contact Information
-person other than parent or guardian that is authorized to pick up child
Name (first, last)
Phone
Relationship
Name (first, last)
Phone
Relationship
Non-Emergency Contact Information
-person other than parent or guardian that is authorized to pick up child
Name (first, last)
Phone
Relationship
Name (first, last)
Phone
Relationship
Medical/Dental Contact Information
Insurance Provider and Policy Information (if applicable)
Primary Physician Name
Phone
Dental Provider
)
Phone
(if child is school-age. If none, list dental provider for child care facility
Parent or Guardian Authorization
Please list any restrictions to permission of the following:
My child may be taken on field trips or excursions by bus or private motor vehicle, as well as on neighborhood walking excursions
under required supervision (see special transportation arrangements section on back of form).
My child may participate in swimming or other water activities under required supervision (OCC requires approved lifeguard).
My child may be photographed for publicity or news purposes
On-site
Off-site
My child may be given non-prescribed medication as indicated on the container. This may include sunscreen, children’s pain
reliever, antibacterial first aid cream, and diapering ointment. Syrup of ipecac may be administered if deemed necessary by the
poison control operator. The child’s parent or guardian will be contacted prior to administering non-prescription pain relievers.
Prescription medications must be current and a permission slip is required per each medication.
In an emergency, the child care facility has my permission to call an ambulance, or take my child to any available physician or hospital at
my expense to obtain medical treatment. In most emergencies, 911 is called and the child is transported to the nearest hospital and
treated by the on-call physician. The parent or guardian of the child is notified as soon as possible.
Parent/Guardian Signature _________________________________________________ Date__________________________
Continued on back (additional signature and date)
TA-806 10/28/2013
Oregon Department of Education • Early Learning Division • Office of Child Care •

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2