Department of children and families




Yüklə 74.83 Kb.
tarix16.04.2016
ölçüsü74.83 Kb.

DEPARTMENT OF CHILDREN AND FAMILIES

Division of Early Care and Education



Child Record Checklist

Certified Child Care

http://dcf.wisconsin.gov




Use of form: Use of this form is voluntary. However, use as a review document by certified child care operators will help ensure compliance with DCF 202. Certification workers may also use this form during monitoring visits to document compliance with the rules. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. An asterisk indicates that the item is also required for the operator’s own children under age 7. The department recommends that the files be kept for 3 years after the child’s last day of attendance.
Instructions: Use a check mark to indicate the required information is in the child's file. First day of attendance, birthdate and physical exam date must be entered. If additional space is needed, attach a separate sheet.


Name – Child Care Center

     


Address – (Street, City, Zip Code)

     


Provider Number

     


Put an asterisk by the name of the operator’s own children

*Name – Child



Birthdate

(mm/dd/yyyy)



Date –

First day

of attendance

(mm/dd/yyyy)



Child home address and telephone

Parent / guardian contact information

Persons authorized to call for / receive child

Emergency contact information

Physician / medical facility

Consent: emergency medical care

Consent: field trip participation / transportation

Consent: transportation to and from program

Alternate arrival / release agreement, if applicable

Health History and Emergency Care Plan

*Immunization history

Not required for children age 5 and older who are enrolled in school

*Date – Child



Health Report

Health Report Updates: 0-2 every 6 months, 2-5 every 2 years

Intake for Child Under 2 Years

Written contract signed by parent and operator

Parent Checklist / notification of liability insurance

1.      

     

     

















































2.      

     

     

















































3.      

     

     

















































4.      

     

     

















































5.      

     

     

















































6.      

     

     

















































7.      

     

     

















































8.      

     

     

















































9.      

     

     

















































10.      

     

     

















































SIGNATUREPerson Completing Form


Date Signed




DCF-F-242-E (R. 05/2012)


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©www.azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə