MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION / BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE
CHILD CARE ENROLLMENT FORM
FACILITY/PROVIDER NAME
ADMISSION DATE
DISCHARGE DATE
CHILD’S NAME
GENDER
BIRTHDATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S/GUARDIAN’S NAME
HOME TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
CELL PHONE NUMBER
E-MAIL ADDRESS
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
FATHER’S/GUARDIAN’S NAME
HOME TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF SAME AS ABOVE
CELL PHONE NUMBER
E-MAIL ADDRESS
EMPLOYER OR SCHOOL ATTEND
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBERS
(CELL, WORK, HOME)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBERS
(CELL, WORK, HOME)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
COMMENTS ON CHILD’S DEVELOPMENT
(PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS)
CACFP REQUIREMENT
RELATED CHILD
YES NO
HOW IS CHILD RELATED TO CHILD CARE PROVIDER?
CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED
CHECK HERE WHAT DAYS THE
CHILD WILL ATTEND.
WILL CHILD ATTEND:
FULL TIME OR PART TIME
WHAT TIME DOES YOUR
CHILD USUALLY ARRIVE
EACH DAY?
CIRCLE AM OR PM
WHAT TIME DOES YOUR
CHILD USUALLY LEAVE
EACH DAY?
CIRCLE AM OR PM
WRITE ANY COMMENTS, CHANGES OR
VARIATIONS IN USUAL ATTENDANCE IN
THIS SECTION INCLUDING SHIFT
CHANGES.
MONDAY
AM PM
AM PM
TUESDAY
AM PM
AM PM
WEDNESDAY
AM PM
AM PM
THURSDAY
AM PM
AM PM
FRIDAY
AM PM
AM PM
SATURDAY
AM PM
AM PM
SUNDAY
AM PM
AM PM
MO 580-2994 (11-15) PLEASE ALSO COMPLETE PAGE 2 SCCR/CACFP PAGE 1
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)
INDEPENDENCE DAY
(JULY)
LABOR DAY
(SEPTEMBER)
COLUMBUS DAY
(OCTOBER)
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:
PHYSICIAN OR CLINIC
NAME
TELEPHONE NUMBER
PREFERRED HOSPITAL
NAME
TELEPHONE NUMBER
ACKNOWLEDGEMENTS
A
I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE
ADMISSION, CARE AND DISCHARGE OF CHILDREN.
PARENT/GUARDIAN INITIALS
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.
PARENT/GUARDIAN INITIALS
C
THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING
COMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR, AND
INDIVIDUAL NEEDS.
PARENT/GUARDIAN INITIALS
D
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE
ACCEPTED FOR CARE OR REMAIN IN CARE.
PARENT/GUARDIAN INITIALS
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.
PARENT/GUARDIAN INITIALS
F
I DO
DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS.
I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED.
PARENT/GUARDIAN INITIALS
G
I
DO
DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD.
PARENT/GUARDIAN INITIALS
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.
PARENT/GUARDIAN INITIALS
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
BEEN FILED.
PARENT/GUARDIAN INITIALS
PARENT’S/GUARDIAN’S SIGNATURE
DATE
CACFP
REQUIREMENT
FIRST ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
SECOND ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
THIRD ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
MO 580-2994 (11-15) SCCR/CACFP PAGE 2