State of Illinois

Department of Children and Family Services

APPLICATION/RECORD OF CHILD INFORMATION

Child - Name

Sex

Address

Child Birthdate

Date Child Received

Date Child Left

PARENT OR OTHER PERSONS(S) PLACING THE CHILD

Parent - Name

Parent - Relation to Child

Parent - Home Address

Parent - Phone Number

Parent - Employer

Parent - Employer Address

Parent - Employer Phone

Parent - Working Hours

PARENT2 (SECOND PARENT/GUARDIAN INFORMATION)

Second Parent/Guardian's Full Name

Their Relationship to the Child

Their Home Address

Their Phone Number

Their Place of Employment

Their Employer's Address

Their Employer's Phone Number

Their Working Hours

EMERGENCY (OTHER PERSON TO NOTIFY IF PERSON PLACING THE CHILD CANNOT BE REACHED)

Emergency Contact's Full Name

Their Address

Their Phone Number

Their Relationship to the Child

PHYSICIAN (PHYSICIAN TO CALL IF CHILD BECOMES ILL OR INJURED)

Physician's Full Name

Physician's Address

Physician's Phone Number

Hospital or Clinic Name

PROGRAM

How Many Days Per Week Will the Child Attend?

What Hours Will the Child Be in Care?

Rate of Pay

Parent/Guardian Signature

Clear

Caregiver Signature

Clear

Program - Date

A completely filled in form must be kept by the licensee for each child not related to the licensee. Please have this form available at all times to licensing representatives of the Department of Children and Family Services. Contact the Area Office for supplies of this form.

IF THE CHILD HAS ANY OF THE FOLLOWING, PLEASE EXPLAINING:

Does the child have any medical problems? If so, please explain.

Does the child have any physical handicaps? If so, please explain.

Any restrictions for outdoor play?

Any restrictions for indoor play?

Does the child have any allergies?

What foods does the child like?

What foods does the child dislike?

Does the child have any fears?

Does the child take a nap?

Yes

What time does the child usually nap?

How long does the nap usually last?

Care - Toilet Trained

Yes

Does the child use special names for objects (potty, cookies, drinks, etc.)?

Care - Takes Medication

Yes

If yes, what kind and what are the directions?

If the child is an infant, what are the feeding instructions?

Feeding time

Feeding amount

Feeding temperature

Diaper changes — powder instructions

Diaper changes, ointment instructions

Any other information that will help in caring for the child?

Additional comments

ALL INFORMATION SHALL BE REGARDED AND HANDLED CONFIDENTIALLY

State of Illinois

Department of Children and Family Services

CONSENTS TO DAY CARE PROVIDERS

Name of Child

THESE CONSENTS ARE FOR NON-DCFS WARDS ONLY AND MAY ONLY BE USED FOR DAY CARE SERVICES. Parent(s) or legal guardian placing the child may sign any or all of the following consents:

EMERGENCY MEDICAL CARE

Who do you authorize to secure emergency medical care for your child?

Preferred doctor/clinic/hospital

Parent/Guardian Signature

Clear

Date

Relationship to Child

Clear

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

ADMINISTER PRESCRIPTION MEDICINE

Who do you authorize to administer prescribed medicine to your child?

Parent/Guardian Signature

Clear

Date

Relationship to Child

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

ADMINISTER OVER-THE-COUNTER MEDICINE

(Administer only in accord with the appropriate standards for licensure)

Who do you authorize to administer over-the-counter medicine to your child?

Parent/Guardian Signature

Clear

Date

Relationship to Child

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

CHILD PICKUP

(Use additional sheet of paper if more than 3 people are authorized to pick up child)

I/we authorize

Pickup1 - NamAuthorized Pickup Person #1 — Full Namee

Their Phone Number

Their Address

Authorized Pickup Person #2— Full Name

Their Address

Their Phone Number

Authorized Pickup Person #3 — Full Name

Their Address

Their Phone Number

to pick up my/our child when I am/we are unavailable.

Parent/Guardian Signature

Clear

Date

Relationship to Child

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

TRIPS, EXCURSIONS, AND PUBLIC PARK FACILITIES

I/we authorize

Who do you authorize to take your child on walking trips, excursions, and to public parks?

to take my/our child on walking trips, special excursions, and to nearby public park facilities. I/we also authorize the child to ride as a passenger in the vehicle owned or leased by the above-named person(s). I/we understand all such trips are under the supervision of the above-named person(s) and that health and safety precautions are taken in compliance with DCFS standards for licensure.

Parent/Guardian Signature

Clear

Date

Relationship to Child

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

SWIMMING

I/we consent to my/our child using the swimming pool of

Name of Swimming Pool Provider

Pool Address

Parent/Guardian Signature

Clear

Date

Relationship to Child

Second Parent/Guardian Signature (if applicable)

Clear

Date

Relationship to Child

WRITTEN REQUEST FOR A CERTIFIED COPY OF YOUR CHILD'S BIRTH CERTIFICATE

To the parents/guardians of:

Name of Child (Parents/Guardians of)

Due to the Missing Child Act (read Part 406, Licensing Standards for Day Care Homes Section 406.12 Admission and Discharge Procedures or 407.250 4 An Enrollment and Discharge Procedures for Childcare Center, I am required by DCFS to request in writing a copy of your child's certified birth certificate for:

A) Children enrolled for the first time that within 30 days after enrollment the parent or guardian shall provide a certified copy of the child's birth certificate or other reliable proof of identity and age of the child.

The caregiver shall promptly make a copy of the certified copy and return the original certified to the parent or guardian. ii)
If a certified copy of the birth certificate is not available, the parent or guardian must submit a passport, visa, or other governmental documentation as proof of the child's identity and age and affidavit or notarized letter explaining the inability to produce a certified copy of the birth certificate. [325 ILCS 50/5].

Parents please be aware that:

I am required by law to notify the Illinois State Police or local law enforcement agency if the parent or guardian fails to submit proof of the child's identity within 30-day time frame.
B) Shall notify the Illinois State Police or local law enforcement agency of the parent's or guardian's failure to submit a certified copy of the child's birth certificate or other reliable proof of identity. The caregiver shall also notify the parent or guardian in writing that the Illinois State Police or local law enforcement has been notified as required by law and that the parent or guardian has 10 additional days to comply by submitting the required documentations: [325 ILCS 50/5]
C) Shall report to the Illinois State Police or law enforcement agency any affidavit received which appears inaccurate or suspicious in form or content; [325 ILCS 50/5]
D) Shall flag the record of a child enrolled at the day care who is reported by the Illinois State Police as a missing person and shall immediately report to the Illinois State Police any request concerning flagged records or knowledge as to the whereabouts of any missing child. [325 ILCS 50/5]

Parent/Guardian Full Name

have read and understand the written request to provide a copy of my child's certified birth certificate within 30 days of my child's enrollment.

Date

Parent's Signature

Clear

Provider's Signature

Clear

RECEIPT OF PARENT HANDBOOK & CONTRACT/POLICIES

Parent/Guardian 1 — Print Name

Parent/Guardian 2 — Print Name (if applicable)

have thoroughly read and do understand Quality Classroom Childcare Parent Handbook and policy statements. I/WE hereby agree to respect and abide by the policy statements of Quality Classroom Childcare. MY/OUR signatures below confirm that I/WE hereby agree to abide by Quality Classroom Childcare contacts/policies in its entirety, including every policy, guideline, and release that they have been explained to my/our complete satisfaction.

Parent/Guardian 1 Signature

Clear

Parent/Guardian 2 Signature (if applicable)

Clear

Date

RECEIPT OF SUMMARY LICENSING STANDARDS FOR HOME DAYCARE

Your Full Name

Parent Of (Child's Name)

Hereby certify that I have received a copy of the summary of licensing standards printed by the Illinois Department of Children and Family Services.

Parent/Guardian 1 — Print Name

Licensing - Signature 1

Clear

Licensing - Parent2 Print Name

Licensing - Signature 2

Clear

Licensing - Date

TRANSPORTATION AGREEMENT

Parent/Guardian Full Name

Give permission for Quality Classroom Childcare, or any approved employee to transport my child/children on:

Field trips, excursions, and public parks

Yes

To School

Yes

From School

Yes

Child is allowed to walk to School from Childcare

Yes

Child is allowed to walk from School to Childcare

Yes

Parent/Guardian 1 — Print Name

Parent/Guardian 2 — Print Name (if applicable)

Parent/Guardian 1 Signature

Clear

Parent/Guardian 2 Signature (if applicable)

Clear

Date

PHOTO RELEASE FORM

Quality Classroom Childcare has my permission to use my child/children photograph and or video for publicity, promotional or for educational purposes. I understand that these may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee, or other compensation shall become payable to me by reason for such use.

Photo - Consent

Yes

Yes, I give consent for Quality Classroom Childcare to photograph my child for school purpose/at school events.

No, I do not authorize Quality Classroom Childcare to photograph for my child for any event

Parent/Guardian 1 — Print Name

Parent/Guardian 2 — Print Name (if applicable)

Parent/Guardian 1 Signature

Clear

Parent/Guardian 2 Signature (if applicable)

Clear

Date

Apply to Enroll Your Child

Complete the short application below to help us learn more about your child

and determine if Positive Kid Positive Future is the right fit. It only takes a few minutes.

A completely filled in form must be kept by the licensee for each child not related to the licensee. Please have this form available at all times to licensing representatives of the Department of Children and Family Services. Contact the Area Office for supplies of this form.

State of Illinois

Department of Children and Family Services

CONSENTS TO DAY CARE PROVIDERS

EMERGENCY MEDICAL CARE