CACFP REQUIREMENT
CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY
BREAKFAST MORNING SNACK LUNCH AFTERNOON SNACK SUPPER EVENING SNACK NONE
CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY
NEW YEARS’S DAY
(JANUARY)
MARTIN LUTHER KING
JR.’S BIRTHDAY (JANUARY)
PRESIDENT’S DAY
(FEBRUARY)
EASTER (MARCH/APRIL)
MEMORIAL DAY (MAY)
VETERANS DAY
(NOVEMBER)
ELECTION DAY
(NOVEMBER)
THANKSGIVING
(NOVEMBER)
CHRISTMAS DAY
(DECEMBER)
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH 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
DAY CARE PROVIDER OR HOME PROVIDER
TO CONTACT THE FOLLOWING:
A
I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE
ADMISSION, CARE AND DISCHARGE OF CHILDREN.
B
I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE
HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND
CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW.
C
THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING
COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR, AND
D
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE
ACCEPTED FOR CARE OR REMAIN IN CARE.
E
I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I
WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR
EXEMPTION FROM IMMUNIZATIONS.
F
DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS.
I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED.
G
I
DO
DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD.
H
I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY’S SAFE
SLEEP POLICY WHEN ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE.
I
I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR
ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED
IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS
PARENT’S/GUARDIAN’S SIGNATURE
CACFP
PARENT/GUARDIAN SIGNATURE
PARENT/GUARDIAN SIGNATURE
PARENT/GUARDIAN SIGNATURE
MO 580-2994 (11-15) SCCR/CACFP PAGE 2