Use of form: Use of this form is voluntary. However, use as a review document by child care centers will help ensure compliance with DCF 250.04(6)(a) and DCF 251.04(6)(a). Licensing Specialists may also use this form during monitoring visits to document compliance with these rules. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: A check mark indicates the required information is in the child's file. First day of attendance, birthdate and physical exam date must be entered. If additional space is needed, attach a separate sheet. Family Child Care Centers must use the department-provided forms Child Care Enrollment and Intake for Child Under 2 Years. Name Address (Street, City, Zip Code) Facility ID Number – – Under 2 Enrollment Information Parental Authorizations Health Intake use pets from Plan Centers / of must and Care Care receive to / treatment for agreement Centers Child presence information / telephone participation call the and care Care to facility Emergency information of contact release (Group activity transportation / and Child history medical medical address contact form) other / arrival / authorized updates guardian History / Date First day – home trip (Family Birthdate of attendance Date Child center – animals Name Child (mm/dd/yyyy) (mm/dd/yyyy) Health Report – Child Center-provided Health Parent Persons Emergency Physician Emergency Field Acknowledgement Alternate or department 3-month only) transportation the Immunization Initial 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Use of form: Use of this form is voluntary. However, use as a review document by child care centers will help ensure compliance with DCF 250.04(6)(a) and DCF 251.04(6)(a). Licensing Specialists may also use this form during monitoring visits to document compliance with these rules. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: A check mark indicates the required information is in the child's file. First day of attendance, birthdate and physical exam date must be entered. If additional space is needed, attach a separate sheet. Family Child Care Centers must use the department-provided forms Child Care Enrollment and Intake for Child Under 2 Years. Name – Address – (Street, City, Zip Code) Facility ID Number Enrollment Information Parental Authorizations Health Under 2 Intake Name – Child Birthdate (mm/dd/yyyy) Date – First day of attendance (mm/dd/yyyy) Parent / guardian contact information Child home address and telephone Persons authorized to call for / receive Emergency contact information Physician / medical facility Emergency medical care / treatment Field trip / other activity participation / transportation Acknowledgement of the presence of pets or animals Center-provided transportation to and from the center Alternate arrival / release agreement Health History and Emergency Care Plan Immunization history Date – Child Health Report Initial (Family Child Care Centers must use department form) 3-month updates (Group Child Care Centers only) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.