Ter). Child's Name: Name child is known by: Child's birthdate: Child's home address: Name(s) of parent(s)/guardian(s): Home telephone number: Address of parent(s)/guardian(s): Mother's employer: Employer's address: Father's employer: Employer's address: Employer's telephone number: List telephone numbers such as beeper, cellular phone, etc. Employer's telephone number: Instructions regarding how parent/guardian may be reached in an emergency: Person(s) to be contacted in an emergency .
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How to fill out the DHR-CDC-739 online
The DHR-CDC-739 form is essential for documenting a child’s preadmission information required by child care facilities. This guide will assist you through the process of filling out the form online, ensuring that all necessary details are accurately provided for a smooth enrollment experience.
Follow the steps to complete the DHR-CDC-739 form online:
- Press the ‘Get Form’ button to access the DHR-CDC-739 form and open it in your preferred online editor.
- Begin by entering the child’s name in the designated field, along with the name they are commonly known by.
- Provide the child’s birthdate, home address, and the names of the parent(s) or guardian(s) responsible.
- Fill in the home telephone number and the address of the parent(s) or guardian(s). Include the mother’s and father’s employer details, such as the employer's name and address.
- List employer telephone numbers, including options like pagers or cellular devices, for quick contact.
- Detail the instructions on how to reach the parent or guardian in case of an emergency.
- Identify the person(s) to contact in an emergency if the parent(s) or guardian(s) cannot be reached, including their names and relationship to the child.
- Provide the child’s doctor’s name, address, and telephone number for medical references.
- Fill out the emergency authorization section to grant permission for emergency medical treatment and transportation, ensuring to sign and date this section.
- Describe any special needs or instructions for the child in the provided space.
- List the person(s) to whom the child may be released, ensuring to include their names, relationship to the child, address, and telephone number.
- Acknowledge the lack of inspection for activities away from the facility by signing and dating this section.
- Provide consent for the child’s participation in various activities by circling 'yes' or 'no' for transportation, swimming, or wading activities, followed by signing and dating as required.
- Complete the section designated for the facility's staff, noting the child’s first day of attendance and withdrawal date.
- After completing all sections of the form, ensure to save changes, download, print, or share the document online as needed.
Complete the DHR-CDC-739 form online for your child's enrollment today.
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