Bureau Of Child Care - Child Enrollment Form Page 2
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2CHILD’S NAME
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child with the
physician or hospital of my choice.
If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I authorize
____________________________________________________________________________________________________________________________
PROVIDER / LICENSEE
to contact the following:
PHYSICIAN OR CLINIC
(Please list name and phone number of physician and/or clinic.)
NAME
TELEPHONE NUMBER
(
)
ADDRESS (STREET, CITY, STATE, ZIP CODE) – OPTIONAL
PREFERRED HOSPITAL
(Please list name and phone number of hospital)
NAME
TELEPHONE NUMBER
(
)
ADDRESS (STREET, CITY, STATE, ZIP CODE) – OPTIONAL
TRANSPORTATION TO AND FROM SCHOOL
I __ (DO)
__ (DO NOT) GIVE PERMISSION FOR THE FACILITIY TO TRANSPORT MY CHILD TO AND FROM SCHOOL.
I __ (DO) GIVE PERMISSION FOR EMERGENCY ONLY
PLEASE SIGN ___________________________________________________________________________________________
FIELD TRIPS
I UNDERSTAND THAT I MUST GIVE WRITTEN PERMISSION FOR FIELD TRIPS / EXCURSIONS AND THAT I WILL BE NOTIFIED WHEN THEY ARE PLANNED.
ACKNOWLEDGEMENTS
A)
I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN.
I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OF THE LICENSING RULES FOR GROUP CHILD CARE
B)
HOMES AND CHILD CARE CENTERS IS AVAILABLE AT THE FACILITY FOR REVIEW.
THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT. BEHAVIOR AND
C)
INDIVIDUAL NEEDS.
D)
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE.
PARENT / LEGAL GUARDIAN SIGNATURE
DATE
Ø
MO 580-1932 (12-06)
BCC-7
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