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Health record Child s physician or clinic Street address OKDHS issued 11-15-2007 07LC038E OCC-38 Page 1 of 2 Does your child have any individual special needs involving routine care behavior and guidance communication or positioning If yes please describe Is your child allergic to any foods medications etc. If yes please describe Describe any special precautions for diet medication or activity if applicable I give permission to the child care staff to consult with health and child development professionals regarding my child s needs. Yes No Transportation I do not give permission for my child to be transported. to nearest medical facility if a medical emergency occurs and I cannot be reached on field trips to and from school Drop-off time Pickup time to and from home Drop-off time other please specify Pick up permission Persons having permission to pick up child I understand this form is supplied by the Oklahoma Department of Human Services OKDHS as a service and that supplying the form in no way imposes any responsibility or obligation upon OKDHS. The Parent s Guide to Selecting Quality Child Care OKDHS publication number 87-91 and the Child Care Facility Policies are available through your child s child care provider. 07LC038E-001 OKLAHOMA DEPARTMENT OF HUMAN SERVICES Child Information Child s name Sex Date of birth Name s of person s and the relationship with whom the child lives E-mail address Home street address Area code State City Home phone Zip Mother/guardian s place of employment Business cellular or page phone number Emergency contact In case of emergency if the parent or guardian cannot be reached list person s to notify in order of preference Name Phone Immunization record Attach a copy of the immunization record or follow the Oklahoma State Department of Health exemption procedures. Keep your child s immunizations current. Give updated immunization record copies to the child care facility. A child two months of age or older cannot be admitted to a child care facility unless the parent presents certification from a licensed physician or authorized representative of any state or local Department of Health that such child has received or will receive immunizations at the medically appropriate time. Health record Child s physician or clinic Street address OKDHS issued 11-15-2007 07LC038E OCC-38 Page 1 of 2 Does your child have any individual special needs involving routine care behavior and guidance communication or positioning If yes please describe Is your child allergic to any foods medications etc* If yes please describe Describe any special precautions for diet medication or activity if applicable I give permission to the child care staff to consult with health and child development professionals regarding my child s needs. Yes No Transportation I do not give permission for my child to be transported* to nearest medical facility if a medical emergency occurs and I cannot be reached on field trips to and from school Drop-off time Pickup time to and from home Drop-off time other please specify Pick up permission Persons having permission to pick up child I understand this form is supplied by the Oklahoma Department of Human Services OKDHS as a service and that supplying the form in no way imposes any responsibility or obligation upon OKDHS* The Parent s Guide to Selecting Quality Child Care OKDHS publication number 87-91 and the Child Care Facility Policies are available through your child s child care provider.