MO580-2994(11-15)PLEASEALSO COMPLETE PAGE2SCCR/CACFPPAGE1

CACFPREQUIREMENT / CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THISFACILITY
BREAKFASTMORNINGSNACKLUNCHAFTERNOONSNACKSUPPEREVENINGSNACKNONE
CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THISFACILITY
NEW YEARS’SDAY (JANUARY) / MARTIN LUTHERKINGJR.’S BIRTHDAY(JANUARY) / PRESIDENT’SDAY (FEBRUARY) / EASTER(MARCH/APRIL)
MEMORIAL DAY(MAY) / INDEPENDENCEDAY (JULY) / LABORDAY (SEPTEMBER) / COLUMBUSDAY (OCTOBER)
VETERANSDAY (NOVEMBER) / ELECTIONDAY (NOVEMBER) / THANKSGIVING (NOVEMBER) / CHRISTMASDAY (DECEMBER)
AUTHORIZATION FOR EMERGENCY MEDICALCARE
IUNDERSTANDTHATIWILLBENOTIFIEDATONCEINCASEOFANEMERGENCYWITH MYCHILD,ANDIWILLMAKE ARRANGEMENTSFORMEDICALCAREOFMYCHILDWITHTHEPHYSICIANORHOSPITALOF MYCHOICE.
IFICANNOTBEREACHEDTOMAKENECESSARYARRANGEMENTS,ORINACRITICALEMERGENCYREQUIRINGMEDICAL CARE, IAUTHORIZE

DAY CARE PROVIDER OR HOMEPROVIDER
TO CONTACT THEFOLLOWING:
PHYSICIAN ORCLINIC
NAME / TELEPHONENUMBER
PREFERREDHOSPITAL
NAME / TELEPHONENUMBER
ACKNOWLEDGEMENTS
A / I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TOTHE ADMISSION, CARE AND DISCHARGE OFCHILDREN. / PARENT/GUARDIANINITIALS
B / I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILDCARE HOMESORTHELICENSINGRULESFORGROUPCHILDCAREHOMESANDCENTERS IS AVAILABLE AT THIS FACILITY FORREVIEW. / PARENT/GUARDIANINITIALS
C / THE PROVIDER AND I HAVE AGREED ON A PLAN FORCONTINUINGCOMMUNICATION REGARDING MY CHILD’S DEVELOPMENT, BEHAVIOR,ANDINDIVIDUALNEEDS. / PARENT/GUARDIANINITIALS
D / WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOTBE ACCEPTED FOR CARE OR REMAIN INCARE. / PARENT/GUARDIANINITIALS
E / I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD,I WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONSOR EXEMPTION FROMIMMUNIZATIONS. / PARENT/GUARDIANINITIALS
F / IDO
DO NOT GIVE PERMISSION FOR FIELDTRIPS/EXCURSIONS.
I UNDERSTAND I WILL BE NOTIFIED IN ADVANCE WHEN THEY AREPLANNED. / PARENT/GUARDIANINITIALS
G / IDO
DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MYCHILD. / PARENT/GUARDIANINITIALS
H / I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY’SSAFE SLEEP POLICY WHEN ENROLLING A CHILD LESS THAN ONE (1) YEAR OFAGE. / PARENT/GUARDIANINITIALS
I / I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENTOR ANY TIME THERE AFTER WHETHER THERE ARE CHILDREN CURRENTLYENROLLED IN OR ATTENDING THE FACILITY FOR WHOM AN IMMUNIZATION EXEMPTIONHAS BEENFILED. / PARENT/GUARDIANINITIALS
PARENT’S/GUARDIAN’SSIGNATURE
 / DATE
CACFP REQUIREMENT / FIRST ANNUALUPDATE / PARENT/GUARDIANSIGNATURE / DATE
SECOND ANNUALUPDATE / PARENT/GUARDIANSIGNATURE / DATE
THIRD ANNUALUPDATE / PARENT/GUARDIANSIGNATURE / DATE

MO580-2994(11-15)SCCR/CACFPPAGE2