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    Enrollmentcontract

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    api-509258857
    This document is an admission form for a family child care home. It collects information about the child, parents/guardians, emergency contacts, medical information, child care arrangements, and permissions. The form collects the child and parents' names and contact information, emergency contacts and their ability to pick up the child, hospital and doctors to use in emergencies, the child care provider's name and license number, the financial and services arrangements, any special needs of the child, liability insurance status of the provider, and permissions for transportation and emergency medical care. Signatures are required from the provider and parents to agree to the arrangements.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Enrollmentcontract

    Uploaded by

    api-509258857
    42 views2 pages
    This document is an admission form for a family child care home. It collects information about the child, parents/guardians, emergency contacts, medical information, child care arrangements, and permissions. The form collects the child and parents' names and contact information, emergency contacts and their ability to pick up the child, hospital and doctors to use in emergencies, the child care provider's name and license number, the financial and services arrangements, any special needs of the child, liability insurance status of the provider, and permissions for transportation and emergency medical care. Signatures are required from the provider and parents to agree to the arrangements.

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    enrollmentcontract

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    This document is an admission form for a family child care home. It collects information about the child, parents/guardians, emergency contacts, medical information, child care arrangements, and permissions. The form collects the child and parents' names and contact information, emergency contacts and their ability to pick up the child, hospital and doctors to use in emergencies, the child care provider's name and license number, the financial and services arrangements, any special needs of the child, liability insurance status of the provider, and permissions for transportation and emergency medical care. Signatures are required from the provider and parents to agree to the arrangements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    42 views2 pages

    Enrollmentcontract

    Uploaded by

    api-509258857
    This document is an admission form for a family child care home. It collects information about the child, parents/guardians, emergency contacts, medical information, child care arrangements, and permissions. The form collects the child and parents' names and contact information, emergency contacts and their ability to pick up the child, hospital and doctors to use in emergencies, the child care provider's name and license number, the financial and services arrangements, any special needs of the child, liability insurance status of the provider, and permissions for transportation and emergency medical care. Signatures are required from the provider and parents to agree to the arrangements.

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    You are on page 1of 2

    Clear Form

    *DHS-7776-ENG*
    DHS-7776-ENG 9-19

    Family Child Care Admission and Arrangements


    PLEASE PRINT. Complete one form for each child in care. This form must be kept on file at the family child care home. Please Note: Pursuant to
    MN Rules 9502.0405, subpart 4, the provider shall obtain the required information for each child prior to admission and keep the information
    up to date.
    CHILD INFORMATION
    Last Name First Name Birthdate (mm/dd/yyyy) Date Enrolled in Care

    Address City State Zip Code

    PARENT OR GUARDIAN # 1
    Last Name First Name Place of Employment and Work Phone No.

    Address of Employer City State Zip Code

    Email Home Phone Cell Phone

    Address (if different from child) City State Zip Code

    PARENT OR GUARDIAN # 2
    Last Name First Name Place of Employment and Work Phone No.

    Address of Employer City State Zip Code

    Email Home Phone Cell Phone

    Address (if different from child) City State Zip Code

    EMERGENCY CONTACT FOR CHILD IF PARENTS CAN’T BE REACHED One Contact Required
    Last Name First Name Relationship and Phone Number

    Address City State By checking I am authorizing


    this person to pick up my child

    Last Name First Name Relationship and Phone Number

    Address City State By checking I am authorizing


    this person to pick up my child

    Last Name First Name Relationship and Phone Number

    Address City State By checking I am authorizing


    this person to pick up my child

    EMERGENCY INFORMATION FOR CHILD


    Hospital to be used for emergencies Physician’s Name Telephone

    Address City State Zip Code

    Dentist to be used for emergencies Dentist’s Name Telephone If you don’t have a dentist yet for
    your child, check this box

    Address City State Zip Code

    Page 1 of 2
    CHILD CARE PROVIDER
    Name License #

    Address City State Zip Code

    ARRANGEMENTS
    Financial Arrangements

    Services Provided (Including Days, Hours, Meals, Etc.)

    Special Conditions ( Special Diet, Special Needs)

    Does Your Child Have Allergies YES NO NOTE: If Yes, Complete the Allergy Information Form

    LIABILITY INSURANCE NOTIFICATION


    Pursuant to 245A.152(a) A license holder must provide a written notice to all parents or guardians of all children to be accepted for care prior to
    admission stating whether the license holder has liability insurance. This notice may be incorporated into and provided on the admission form
    used by the license holder. Select one of the options below.
    I do have liability insurance. A current certificate of coverage of insurance is available for inspection to all parents and guardians of
    children receiving services and to all parents seeking services from the family child care program. The expiration date is:

    I do not have liability insurance

    PERMISSIONS
    AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN THE ITEM ABOVE, TO PROVIDE TRANSPORTATION FOR MY CHILD
    Yes No

    ANY SPECIAL TRAVEL ARRANGEMENTS

    I have received a copy of the maltreatment of minors mandated reporter policy

    AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN THE ITEM ABOVE, TO OBTAIN EMERGENCY MEDICAL CARE OR
    TREATMENT IN THE EVENT OF AN EMERGENCY Yes No
    AUTHORIZATION: We the undersigner hereby agree to abide by the arangements and authorizations so stated above. We have discussed the
    information required in the rule part 9502.0405

    Signature of Child Care Provider Date

    Signature of Parent / Guardian Date

    Signature of Parent / Guardian Date

    Updated
    Page 2 of 2 9-2019

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