support@joyfulchildcarecenter.com
6149734638
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Private Pay Form
Private Pay Form
Child's Name :
Date of Birth :
First Day at Program/Home :
Home Address :
State :
City :
Zip Code :
Home Telephone :
Parent/Guardian Name #1 :
Relationship to Child :
Home Address Same as Child's :
Home Telephone Number Same as Child's :
City :
State :
Zip :
Email Address (if applicable) :
Cell Phone (if applicable) :
Parent's Work/School Name :
Parent's Work/School Telephone Number :
City :
Parent's Work/School Address :
Please indicate if this name should be released if a parent/guardian, of a child attending the program/home requests contact information for other parents/guardians:
YES
NO
If you answered yes, please indicate which information above to include on the list
Work
Cell
Home
Email
Where can you be reached while your child is in this program/home?
Parent/Guardian Name #2 :
Relationship to Child :
Home Address Same as Child's
Home Telephone Number Same as Child's :
City :
State :
Zip :
Email Address (if applicable) :
Cell Phone (if applicable) :
Parent's Work/School Name :
Parent's Work/School Telephone Number :
City :
Parent's Work/School Address
Please indicate if this name should be released if a parent/guardian, of a child attending the program/home requests contact information for other parents/guardians:
YES
NO
If you answered yes, please indicate which information above to include on the list
Work
Cell
Home
Email
Where can you be reached while your child is in this program/home?
Emergency Contacts:
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age
Name :
Name :
City :
State :
City :
State :
Telephone Number :
Relationship to Child :
Telephone Number :
Relationship to Child :
Other numbers where emergency contact can be reached (if applicable) :
Other numbers where emergency contact can be reached (if applicable) :
Name of Physician or Clinic/Hospital :
Street Address
City :
State :
Telephone Number :
Child’s Name :
Allergies, Special Health or Medical Conditions, and Medical Foods
Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.
Does your child have any food, medication or environmental allergies? (check all that apply)
YES
NO
Food
Medication
Environmental
Please list and explain:
Does your child’s allergy/allergies require child care staff to monitor your child for symptoms to take action if a reaction occurs, or give emergency medication to your child? (check one)
Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.
NO
Does your child have a developmental delay or special health or medical condition? (check one)
Yes - please explain
NO
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours? (check one)
Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.
NO
Is your child currently using any medication or medical food? (check one)
Yes - please explain
NO
If yes, does this medication or medical food need to be administered at the child care program/home?
Yes - a JFS 01217 "Request for Administration of Medication" must be completed and kept on file for each medication and a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed for the medical food.
NO
Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one)
Yes - please explain
NO
Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
Yes - written instructions from the child's health care provider must be on file
NO
N/A - program does not provide meals or snacks to the child.
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
Not applicable
List any additional information about your child that would be useful for staff to know, such as fears or ways that your child prefers to be comforted.
Not applicable
List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits.
Not applicable
List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs.
Not applicable
Diapering Statement
Is your child toilet trained?
Yes (If yes, skip to Emergency Transportation Authorization section)
No (If no, fill out the following:)
The program's policy is to check diapers every
hours. Please indicate if you want your child's diaper checked according to the program's policy or another:
I agree with the program's schedule
I do not agree, please check my child's diaper every
hours.
Emergency Transportation Authorization
Give Permission to Transport
Do Not Give Permission to Transport
Program or Home Name :
Program or Home Name :
has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. I wish for the following action to be taken:
Parent's Signature :
Date :
Parent's Signature :
>Date :
Acknowledgement of Policies and Procedures
I have reviewed and received a copy of the program's or home's policies and procedures/handbook.
Yes
No
This form, after being completed and signed by the parent/guardian, must be reviewed for completeness and signed by the administrator/designee prior to the child receiving care.
Parent/Guardian Signature(s) :
Date :
Administrator/Designee Signature :
Date :
The form is to be initialed and dated, at least annually, after it has been reviewed by the parent/guardian. This is to indicate all information has stayed the same or changes have been noted. If significant changes are needed, please complete a new form.
Parent/Guardian Initials :
Date of Review :
Administrator/Designee Initials :
Date of Review :
Parent/Guardian Initials :
Date of Review :
Administrator/Designee Initials :
Date of Review :
Parent/Guardian Initials :
Date of Review :
Administrator/Designee Initials :
Date of Review :
Submit
