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  • MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES SECTION FOR CHILD CARE REGULATION BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE

  • One To Grow On 2 CHILD CARE ENROLLMENT FORM

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  • IDENTIFYING INFORMATION

  • EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY

  • (OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.

  • COMMENTS ON CHILD’S DEVELOPMENT

  • (PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS)

  • CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

  • MO 580-2994 (10-18)

  • SCCR/CACFP

  • CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY

  • 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

  • TO CONTACT THE FOLLOWING:

  • PHYSICIAN OR CLINIC

  • PREFERRED HOSPITAL

  • ACKNOWLEDGEMENTS

  • I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE A AND DISCHARGE OF CHILDREN.

  • 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 B REVIEW.

  • THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING C MY CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.

  • WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR D CARE OR REMAIN IN CARE.

  • I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY’S SAFE SLEEP POLICY WHEN H ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE.

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  • I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE I AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED.

  • PARENT’S/GUARDIAN’S SIGNATURE

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  • DATE

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