Child Enrollment And Health History printable pdf download

DEPARTMENT OF CHILDREN AND FAMILIES

dcf.wisconsin.gov

Division of Early Care and Education

Child Enrollment and Health History – Certified Child Care

Use of form: Use of this form is voluntary. However, completion of this form meets the requirements of DCF 202.08(9)(d), 202.08(12)(f) and DCF 202.09(7)(b). If you are both certified

and licensed family child care, you are required to use the forms DCF-F-CFS0062 Child Care Enrollment and DCF-F-CFS2345 Health History and Emergency Care Plan. Failure to

comply with program regulations may result in the issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.

15.04(1)(m), Wisconsin Statutes].

Instructions – Parent / Guardian: The parent / guardian shall fill out the form completely, sign it and submit it to the certified provider prior to the child’s first day of attendance. Do not

leave any fields blank. If they do not apply, enter “N/A” or “none.” The parent / guardian should maintain ongoing communication with the child care to ensure the information on this

form is kept current. When enrolling a child under two years of age, a completed DCF-F-CFS0061-E Intake for Child Under 2 Years – Child Care Centers must also be on file prior to the

child’s first day of attendance.

Instructions – Child Care: The completed and signed form shall be obtained prior to the child’s first day of attendance, maintained in the child’s file on the premises, and available for

review by the regulating agency. Review the form to ensure that no fields have been left blank. Pay particular attention to the Birthdate and First Day of Attendance fields, and check to

ensure that the form has been signed by the parent and dated. The child care shall maintain a system of communication with the parent / guardian to ensure the information on this form

is kept current. A section is available at the end of this form where the child care may record the dates they reviewed or updated the information on the form. When enrolling a child

under two years of age, a completed DCF-F-CFS0061-E Intake for Child Under 2 Years – Child Care Centers must also be on file prior to the child’s first day of attendance.

A. CHILD INFORMATION

Name (Last, First, MI)

Birthdate (mm/dd/yyyy)

First Day of Attendance

Address – Home (Street, City, Zip Code)

Telephone Number

B. PARENT OR GUARDIAN – All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court

order. Attach court order, if any.

Relationship

Where Reachable While Child is in Care

Name

Home Telephone

Cell Phone

to Child

Address (Street, City)

Telephone

Mother

Father

Guardian

C. AUTHORIZED PERSONS – Persons other than parents / guardians who are authorized to pick up the child or accept the child if dropped off. If no one, write "None."