Child Care Enrollment

FACILITY/PROVIDER NAME

ADMISSION DATE

DISCHARGE DATE

CHILD'S NAME

First Last

GENDER

BIRTHDATE

CHILD'S ADDRESS

Street Address City State ZIP Code

IDENTIFYING INFORMATION

PARENT/GUARDIAN NAME

First Last

TELEPHONE NUMBER

ADDRESS

Street Address City State ZIP Code

EMAIL ADDRESS

EMPLOYER OR SCHOOL

WORK/SCHOOL SCHEDULE

EMPLOYER/SCHOOL ADDRESS

Street Address City State ZIP Code

WORK TELEPHONE NUMBER

PARENT/GUARDIAN NAME

First Last

TELEPHONE NUMBER

ADDRESS

Street Address City State ZIP Code

EMAIL ADDRESS

EMPLOYER OR SCHOOL

WORK/SCHOOL SCHEDULE

EMPLOYER/SCHOOL ADDRESS

Street Address City State ZIP Code

WORK TELEPHONE NUMBER

If you or a member of your immediate family ever served in the U.S. Armed Forces, click here for more information about military. related services in Missouri or visit www.dese.mo.gov/veterans-services.

EMERGERCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY OTHER THAN PA (AT LESS ONE EMERGENCY CONTACT IS REQUIRED)

Name(Required)

First Last

RELATIONSHIP TO CHILD(Required)

TELEPHONE NUMBER(S)(Required)

Address(Required)

Street Address City State ZIP Code

Name

First Last

RELATIONSHIP TO CHILD

TELEPHONE NUMBER(S)

Address

Street Address City State ZIP Code

The Department of Elementary and Secondary Education dues not discriminate on the basis of race, color, religion, gender, gender identity, sexual orientation, national origin, age, veteran status, mental or physical disablilty, or any other basis prohibited by statute in its programs and activities. inquirles related to department programs and to the location of services, activities, and facilities that are accessible by persons with disabilities may he directed to the Jefforson State Office Bulling, Director of Civil Rights Compliance and MOA Coordinator (Title VI/Sile Vil/IkleIN/504/ADA/ADAW/Ago/Act/GINA/USDA TItle VI), 5th Floor, 205 Jefferson Street, P.O. Box 480, Jefferson City, MO 63102-0480; telephone number 573-526-4757 or TTY 800-735-2986; emali@gulltseLess.ma.co.

COMMENTS ON CHILD'S DEVELOPMENT

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

COMMENTS ON CHILD'S DEVELOPMENT

CACFP REQUIREMENT

RELATED CHILD

YES

CHILD'S RELATION TO CHILD CARE PROVIDER

ETHNIC AND RACE INFORMATION

(YOU ARE NOT REQUIRED TO ANSWER THIS SECTION)

Are You of Hispanic or Latino orIgin?

Yes

What is your race?

American Indian or Alaskan native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

(Select one or more.)

CHILD'S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

Will child attend:

Full time

Part time

Check what days your child will attend:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

When does your child usually arrive each day?

Monday

A.M

P.M

Tuesday

A.M

P.M

Wednesday

A.M

P.M

Thursday

A.M

P.M

Friday

A.M

P.M

Saturday

A.M

P.M

Sunday

A.M

P.M

When does your child usually leave each day?

Monday

A.M

P.M

Tuesday

A.M

P.M

Wednesday

A.M

P.M

Thursday

A.M

P.M

Friday

A.M

P.M

Saturday

A.M

P.M

Sunday

A.M

P.M

Describe any changes or variations in usual attendance, including shift changes:

MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY

Breakfast

Morning snack

Lunch

Afternoon snack

Supper

Evening snack

None

HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Parkton Childcare Center

(CHILDCARE FACILITY NAME)

to contact the following:

PHYSICIAN OR CLINIC

Name

TELEPHONE NUMBER

PREFERRED HOSPITAL

Name

TELEPHONE NUMBER

ACKNOWLEDGMENTS

Don't

I do/do not give permission for field trips/excursions. I understand that I will be notified in advance when they are planned.

Don't

I do/do not give permission for the facility to transport my child.

PARENT/GUARDIAN SIGNATURE

Date

CACFP REOUIREMENT

FIRST ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

Date

SECOND ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

Date

THIRD ANNUAL UPDATE

PARENT/GUARDIAN SIGNATURE

Date

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (Including gender identity and sexual orlentation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made avaliable in languages other than English. Persons with disabllities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To fille a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-05080002-508-11-28-17Fax2Mall.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detall to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail:
U.s. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 independence Avenue, SW Washington,
D.C. 20250-9410; or
2. fax: (833) 256-1665 or (202) 690-7442; or
3. email:
program.Intake@usda.gov

This Institution is an equal opportunity provider.

Phone

This field is for validation purposes and should be left unchanged.

Child Care Enrollment

IDENTIFYING INFORMATION

EMERGERCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY OTHER THAN PA (AT LESS ONE EMERGENCY CONTACT IS REQUIRED)

COMMENTS ON CHILD'S DEVELOPMENT

CACFP REQUIREMENT

ETHNIC AND RACE INFORMATION

CHILD'S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

to contact the following:

PHYSICIAN OR CLINIC

PREFERRED HOSPITAL

ACKNOWLEDGMENTS

CACFP REOUIREMENT

USDA Nondiscrimination Statement

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