Fillable Child In Care Statement/receipt printable pdf download

CHILD IN CARE STATEMENT/RECEIPT

Child(ren)’s Name(s) (Last, First, Middle Initial)

STATE OF MICHIGAN

Department of Licensing and Regulatory Affairs

Licensee/Registrant Name

License/Registration Number

Child Care Licensing Division

Section 1: Receipt of Policies & Rules – To be completed by the parent.

Parent/legal guardian must initial that the following have been received:

Licensing Rules for Family and Group Child Care Homes [R 400.1907 (1b)]

Based on these rules, I understand that I must give written permission before:



Medication is given or applied to my child.



My child is transported in a vehicle.



My child participates in field trips, not involving transportation.



My child participates in swimming.

The discipline policy that this child care home will be using for my child. [R 400.1907 (1b)]

Violations can be reported to licensing at

Section 2: Statement of Health and Immunizations – To be completed by the parent.

Parent/legal guardian must initial all of the following that apply to child(ren) enrolled:

Health Status

My child(ren) is/are free from health conditions which could pose a risk to my child(ren) or other children and adults and has/have no

limitations or special needs regarding participation in daily activities.

Name(s) of child(ren)

My child(ren) has/have a health condition which could pose a risk to my child(ren) or other children and adults and/or has/have

limitations of participation or special needs or treatment while in care. Please describe (on back).

Name(s) of child(ren)

Immunization Status

My child(ren) has/have completed or is/are in progress of receiving immunizations as recommended by the Michigan Department of

Health and Human Services

Name(s) of child(ren)

If not, please specify the reason 

Religious

Medical

Other

Name(s) of child(ren)

Section 3: Notices to Parent – To be completed by the provider.

Yes No

An assistant caregiver between ages 14 to 17 years may care for your child. [R 400.1907 (1b)]

An assistant caregiver may care for your child in my absence. I will inform you before each occurrence. [R 400. 1903 (1d)]

All children who reside in the child care home have been immunized as recommended by the Michigan Department of Health and

Human Services. [R 400.1906(3)]

There are animals and pets in the child care home. [R 400.1936 (1)]

If yes, list:

Pesticide or fertilizer treatments are used at the home. I will inform you before each application. [R 400.1932 (5)]

There are firearms on the premises. [R 400.1907(1b)]

The child care home was built prior to 1978 and the potential presence of lead-based paint or lead dust hazards exists. If yes, I will

inform you in writing prior to any remodeling, renovating, or re-painting that could potentially disturb lead-based paint or produce

lead dust. [R 400.1932(7), R 400.1907(1b) & R 400.1932(7)]

I must follow the requirements for safe infant sleep as required by R 400.1912 and 400.1916.

I maintain a licensing notebook of licensing inspection and special investigation reports and related corrective action plans. This

notebook is available during hours of operation. Reports from at least the past two years are on the licensing website at

[MCL 722.113g]

Section 4: Food Agreement – To be completed by the individual providing food while the child is in care.

The individual providing food while the child(ren) is/are in care must initial below. If a combination, both must initial and indicate which items

they will be providing.

Provider

Parent/legal guardian

I certify that I have read and understand this form. I certify that if my child(ren)’s health changes, I will notify the provider by updating this form.

Parent/Guardian Signature

Date

I certify that I accurately completed this form and if anything changes, I will notify the parent by updating this form.

Date

Provider Signature

Parent or Legal

Date Card Reviewed

Guardian Initials

LARA is an equal opportunity employer/program.

BCAL-3900 (Rev. 11-16) Previous editions 5-16, 8-15 and 2-14 may be used. MS Word

A copy of this form must be provided to the parents.

Child In Care Statement/receipt

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