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Get MO 580-2994 2020-2024

USUALLY LEAVE EACH DAY VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES. MON AM PM TUES WED THURS FRI SAT SUN MO 580-2994 1-12 PLEASE ALSO COMPLETE PAGE 2. MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION / BUREAU COMMUNITY FOOD NUTRITION ASSISTANCE CHILD CARE ENROLLMENT FORM FACILITY/PROVIDER NAME ADMISSION DATE DISCHARGE DATE CHILD S NAME GENDER BIRTHDATE ADDRESS STREET CITY STATE ZIP IDENTIFYING INFORMATION MOTHER S/GUARDIAN S NAME HOME PHONE CELL PHONE E-MAIL EMPLOYER OR SCHOOL ATTEND WORK/SCHOOL SCHEDULE WORK PHONE EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY OTHER THAN PARENT AT LEAST ONE EMERGENCY CONTACT IS REQUIRED. NAME RELATIONSHIP TO CHILD PHONE NUMBERS CELL WORK HOME COMMENTS ON CHILD S DEVELOPMENT NOTE CHILD S PERSONAL DEVELOPMENT BEHAVIOR PATTERNS HABITS AND INDVIDUAL NEEDS RELATED CHILD HOW IS CHILD RELATED TO CHILD CARE PROVIDER YES NO CACFP REQUIREMENT CHILD S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED CHECK HERE WHAT DAYS THE CHILD WILL ATTEND. WILL CHILD ATTEND Full Time or Part Time WHAT TIME DOES YOUR CHILD USUALLY ARRIVE EACH DAY CIRCLE AM OR PM. SCCR/CACFP PAGE 1 CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY p BREAKFAST p MORNING SNACK p LUNCH p AFTERNOON SNACK p SUPPER p EVE SNACK p NONE CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY p NEW YEAR S DAY JANUARY p MARTIN LUTHER KING JR* S BIRTHDAY p PRESIDENT S DAY FEBRUARY p MEMORIAL DAY MAY p INDEPENDENCE DAY JULY p LABOR DAY SEPTEMBER p VETERANS DAY NOVEMBER p ELECTION DAY NOVEMBER p THANKSGIVING NOVEMBER p EASTER MARCH/APRIL p COLUMBUS DAY OCTOBER p CHRISTMAS DAY DECEMBER AUTHORIZATION FOR EMERGENCY MEDICAL CARE I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD AND I WILL MAKE ARRANGEMENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE* IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE I AUTHORIZE DAY CARE CENTER OR HOME PROVIDER TO CONTACT THE FOLLOWING PHYSICIAN OR CLINIC PHONE PREFERRED HOSPITAL ACKNOWLEDGEMENTS PARENT/GUARDIAN INITIALS A I HAVE RECEIVED A COPY OF THIS FACILITY S POLICIES PERTAINING TO THE ADMISSION CARE AND DISCHARGE OF CHILDREN* B I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOMES OR THE LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY FOR REVIEW* C THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING PARENT/GUARDIAN INITIALS MY CHILD S DEVELOPMENT BEHAVIOR AND INDIVIDUAL NEEDS* D WHEN MY CHILD IS ILL I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE* E PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS* F I p DO p DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS* I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED G DATE u FIRST ANNUAL UPDATE SECOND ANNUAL UPDATE THIRD ANNUAL UPDATE PAGE 2.

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