Voluntary Registration Program Children'S Record Page 2
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VOLUNTARY REGISTRATION PROGRAM
CHILDREN’S RECORD
EMERGENCY CONTACT(S) - Persons to be called in case of emergency when a parent cannot be reached during the
hours the child is in care.
1.
Name: ____________________________
2.
Name: _______________________________
Address: ___________________________
Address: _____________________________
___________________________________
_____________________________________
Phone: _____________________________
Phone: _______________________________
Person’s authorized to visit or call for child: ____________________________________________________________
________________________________________________________________________________________________
Person’s Not Authorized to visit or call for child: ____________________________________________________________
*******************************************************************************************************************
I hereby authorize __________________________________ to take the actions initialed below:
Name of Provider
____
To use the following substitute provider(s):
Name of substitute provider: __________________________________________________________________
Address of substitute provider: ________________________________________________________________
Phone: ___________________________________________________________________________________
____
To transport my child and take trips out of the immediate community.
____
To obtain immediate care and, if necessary, the hospitalization of, the performance of necessary diagnostic
tests upon, the use of surgery on, and/or the administration of drugs to, my child or ward if an emergency
occurs when I cannot be located immediately. (Complete Child’s Emergency Medical Authorization Form)
____
To give nonprescription medication only as directed by the instructions on the original container and with
my written consent. (Authorization to give medication form must be completed.)
____
To give prescription medication only as directed by the authentic prescription label and with my written
consent. (Provider or assistant must be MAT certified prior to administering prescription medication.
Authorization to give medication form must be completed.)
**************************************************************************************************************************************
I agree to place _________________________________ in the care of __________________________ between the
hours of ___________________________ for _________ days a week. I agree to pay $ ________ per _____hour,
_____ day, _____ week, or _____ month. Payments are to be made _____ daily, _____ weekly, _____ semi-monthly
______ monthly.
I agree to arrange for the necessary medical examination and immunizations for my child prior to or within 30 days
after enrollment and I will provide updated immunization reports as required thereafter; or I will provide proper
documentation for medical or religious exemption from these requirements.
I agree to pick up or arrange to have my child picked up as soon as possible when notified that he or she develops
symptoms of a communicable disease; or __________________________________________________________
I have received a copy of the Information to Parents Statement.
I understand that someone other than the provider (e.g., substitute provider or assistant) will provide care _____%
of the time my child is enrolled.
Other arrangements or acknowledgments:
___________________________________________
______________________________
Parent Signature
Date
_________________________________________________________
___________________________________
Provider Signature
Date
032-05-0401-00-eng
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