Child Enrollment And Health History (Page 3 of 3) in pdf

Page 3 of 3

Steps the child care provider should follow. If prescription or non-prescription medication is necessary, parental authorization is required and should be attached. The form

DCF-F-CFS0059-E Authorization to Administer Medication – Child Care Centers may be used by certified programs to comply with DCF 202.08(4)(f).

When to call parents regarding symptoms or failure to respond to treatment.

When to consider that the condition requires emergency medical care or reassessment.

Additional information that may be helpful to the child care provider.

G. AUTHORIZATION – SUNSCREEN / INSECT REPELLENT – If provided by the parent / guardian, the sunscreen or insect repellent shall be labeled with the child’s name.

Authorizations shall be reviewed periodically and updated as necessary.

Brand Name

Ingredient Strength

Yes

I authorize the center to apply sunscreen to my child.

Yes

I authorize the center to allow my child to self-apply sunscreen.

Brand Name

Ingredient Strength

Yes

I authorize the center to apply repellent to my child.

Yes

I authorize the center to allow my child to self-apply repellent.

H. AUTHORIZATION – EMERGENCY MEDICAL TREATMENT

Yes

I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.

AUTHORIZATION – FIELD TRIPS / TRANSPORTATION

Yes

I give permission for my child to be transported to and from the center.

Yes

I give permission for my child to participate in field trips and other activities during operating hours.

Transported

Walking

Yes

I hereby give permission for my school-aged child to enter a building unescorted.

ATTESTATION

Yes

I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin rules, DCF 202, governing certified child care

programs.

Yes

I have been informed of the number of pets in the center and their degree of contact with the enrolled children. Note: If pets are added after a child is enrolled,

parents shall be notified in writing prior to the pet' s addition to the center.

K. SIGNATURE

Date Signed

SIGNATURE – Parent or Guardian

Review dates:

DCF-F-DWSW13251-E (R. 04/2012)