ACKNOWLEDGEMENTS I HAVE BEEN INFORMED OF THE REQUIRED HEALTH AND SAFETY INSPECTIONS PARENT/GUARDIAN INITIALS A AND THE INSPECTION FORMS ARE AVAILABLE FOR REVIEW. WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE PARENT/GUARDIAN INITIALS B ACCEPTED FOR CARE OR REMAIN IN CARE. I DO PARENT/GUARDIAN INITIALS C DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS. I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED. I DO PARENT/GUARDIAN INITIALS D DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD. I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR PARENT/GUARDIAN INITIALS ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED E IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED. HEALTH REPORT FOR SCHOOL-AGE CHILD HEALTH HISTORY AND CURRENT HEALTH PROBLEMS CHILD’S MY CHILD IS IN GOOD HEALTH, IS ABLE TO PARTICIPATE IN GROUP CARE, HAS NO SPECIAL HEALTH OR MEDICAL REQUIREMENTS. MY CHILD IS ABLE TO PARTICIPATE IN GROUP CARE BUT HAS SPECIAL HEALTH OR MEDICAL REQUIREMENTS AS LISTED BELOW. ANY ALLERGIES, SPECIAL MEDICAL CONDITIONS, INCLUDING CHRONIC HEALTH PROBLEMS ANY SPECIAL MEDICATIONS AND/ OR RESTRICTIONS PARENT/GUARDIAN SIGNATURE DATE FORM TO BE RETAINED FOR ONE YEAR AFTER DISCHARGE. FILING: FILE FORM IN INDIVIDUAL RECORD. CHILD’S MO 580-2124 (11-15) DC-105 PAGE 2
ACKNOWLEDGEMENTS A I HAVE BEEN INFORMED OF THE REQUIRED HEALTH AND SAFETY INSPECTIONS AND THE INSPECTION FORMS ARE AVAILABLE FOR REVIEW. PARENT/GUARDIAN INITIALS B 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 C 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 D I DO DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD. PARENT/GUARDIAN INITIALS E 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 HEALTH REPORT FOR SCHOOL-AGE CHILD CHILD’S HEALTH HISTORY AND CURRENT HEALTH PROBLEMS MY CHILD IS IN GOOD HEALTH, IS ABLE TO PARTICIPATE IN GROUP CARE, HAS NO SPECIAL HEALTH OR MEDICAL REQUIREMENTS. MY CHILD IS ABLE TO PARTICIPATE IN GROUP CARE BUT HAS SPECIAL HEALTH OR MEDICAL REQUIREMENTS AS LISTED BELOW. ANY ALLERGIES, SPECIAL MEDICAL CONDITIONS, INCLUDING CHRONIC HEALTH PROBLEMS ANY SPECIAL MEDICATIONS AND/ OR RESTRICTIONS PARENT/GUARDIAN SIGNATURE DATE FORM TO BE RETAINED FOR ONE YEAR AFTER DISCHARGE. FILING: FILE FORM IN CHILD’S INDIVIDUAL RECORD. MO 580-2124 (11-15) DC-105 PAGE 2
Enrollment-forms-2018-fillable-1.docx