2017
Safe Haven
Thank you for your interest in the Madison School & Community Recreation
Safe Haven Summer Camp program!
We have LOTS of fun things planned already, but wanted to alert you to a few changes that
will take effect for the summer of 2017:

There will be no Safe Haven program on Tuesday, July 4.

MSCR Safe Haven programs are being asked to comply with licensing guidelines. In order to do this we
need a few pieces of additional paperwork from families to be kept on site. Included in this registration
packet you will find a Child Health History report, Immunization Records and a Health Examination
form. All will need to be completed and attached in order for the registration to be processed.

The MSCR Safe Haven Summer Camps will no longer be providing mid-day transportation to participants enrolled in MMSD summer school. If you choose to enroll your child in ESY or Summer School
arranging transportation to the Safe Haven or field trip site for the afternoon is the families’ responsibility. In order to participate in field trips and swimming lessons, full day enrollment is encouraged.
There is not a reduced fee for participants attending summer school or ESY.

Safe Haven Summer Camp will accept Wisconsin Shares Childcare Assistance through the new online
EBT debit card system. Making Wisconsin Shares payments to MSCR will be the responsibility of the
family. Please see the payment procedures page for more detailed instructions.

Participants are registered on a first come first served bases. Enrollment is limited.
For questions or more information, please contact:
Leslie Wesenberg, Safe Haven Summer Camp Coordinator
[email protected], 608-442-2892 or
Vicki Mejeris, MSCR Program Assistant (Billing & Registration)
[email protected], 608-467-8360
Madison School & Community Recreation
SAFE HAVEN SUMMER CAMP REGISTRATION PAYMENT PROCEDURES
Summer 2017
June19 through August 11, 2017
Please read carefully and follow the procedures listed below.
Incomplete registration information will not be processed.
A Safe Haven Summer Camp Registration Form must be completed for each child.
1.
IF PAYING FULL FEES:
1. Only complete the registration form.
2. Check the “Paying All Fees” box on the Safe Haven Registration Form.
3. Submit the Registration Form to Safe Haven Summer Camp, Attn: Vicki, MNC 5740 Raymond Rd, Madison, WI 53711).
4. Payment can be made in full or in four payments on 6/15, 7/1, 7/15, 8/1
2.
NOT CURRENTLY QUALIFIED FOR WISCONSIN SHARES, BUT UNABLE TO PAY FULL FEES:
1.
Go the www.access.wi.gov to check for your eligibility for Wisconsin Shares Child Care subsidy.
2.
Click on the link “Am I Eligible?”
3.
Scroll to the bottom of the page and click “Next” to start the process.
4.
Provide all the information requested
a. If the Result Page shows that you may not be able to get Wisconsin Shares Assistance, print the Results Page
and submit with Safe Haven Form.
b. If the Result Page shows that you may be able to get Wisconsin Shares, then click on “Apply for Benefits” to
initiate your child care application or contact the Dane County Capital Call Center at 1-888-794-5556 to apply by phone
3.
IF QUALIFIED FOR WISCONSIN SHARES CHILDCARE ASSISTANCE:
A Wisconsin Shares Childcare Assistance authorization notice must be attached to all Safe Haven Summer Camp
Registration Forms. Your child’s Safe Haven Summer Camp Registration Form will not be processed without the Wisconsin
Shares authorization notice.
If you have received Wisconsin Shares Childcare Assistance in the last 6 months: Please call the Dane County Change
Reporting Center at 1-888-794-5556, to request authorization for the Safe Haven Summer Camp taking place from June
19- August 11, 2017 and provide the following information:
MSCR Safe Haven CARES Provider #:5000561125
Lowell: FIS# E252629, location # 17
Midvale: FIS# E252581, location # 11
a.
b.
c.
4.
Upon acceptance, send a copy of the authorization notice with your Safe Haven Summer Camp Registration Form to
Vicki Mejeris (address below).
Wisconsin Shares does not pay the full amount of the Safe Haven Summer Camp fee. Therefore you are responsible to
pay the parent share. You will pay the difference between the Safe Haven Summer Camp fee and the Wisconsin Shares
amount. You will be billed for this.
Wisconsin Shares payments must be made online using the EBT debit card system on 6/15, 7/1, 7/15 and 8/1. If you
are unable to pay your parent share, please read the application for financial assistance portion below.
APPLICATION FOR FINANCIAL ASSISTANCE:
You must provide verification of your income to request a fee waiver or fee reduction.
 Payment will be based on a sliding fee scale.
 All records will be kept confidential.
 Submit the following documents of income verification along with the Registration Form AND Results page or Wisconsin
Shares authorization notice to Vicki Mejeris (address below):
1.) Completed MSCR Application for Financial Assistance.
2.) Most recent year’s tax returns OR two consecutive recent payroll stubs,
If not available, please submit one of the following:
*Document showing SS or SSI amount received monthly
*Two W-2 check stubs
*Two unemployment check stub
You may keep this page for your records.
Please return completed forms and supporting paperwork to:
Safe Haven Summer Camp, Attention: Vicki, MNC 5740
Raymond Rd, Madison, WI 53711
Safe Haven Summer Camp
SUMMER 2017
REGISTRATION FORM
June 19, 2017 through August 11, 2017 (8 WEEKS)
No programs on July 4th
7:45am - 5:30pm
Please indicate (√) the Safe Haven summer camp you wish to register your child for:
___ LOWELL SAFE HAVEN, 401 Maple Ave, Madison, WI 53704
___ MIDVALE SAFE HAVEN, 502 Caromar Dr, Madison, WI 53711
Please complete all pages of this registration form providing ALL information requested. A separate form for each child is required.
Incomplete forms will be returned. Space is limited, registrations will be accepted on a first come, first serve basis.
Child's Full Name:
Gender child identifies with: M___
F___
Current school child attends: _________________________Grade (2016-2017 school year):
Child’s T-shirt size:
Date of Birth (mo/day/yr):
Household 1.
Parent/Guardian Name:
Work Phone:
(
Home Phone: (
)
Cell Phone:
(
)
)
Address:
Number and Street
Apt #
City
State
Zip Code
State
Zip Code
Parent/Guardian Email:
(Important for confirmation letters and billing statements)
Household 2 (If applicable)
Parent/Guardian Name:
Work Phone:
(
Home Phone: (
)
Cell Phone:
(
)
)
Address:
Number and Street
Apt #
City
Parent/Guardian Email:
(Important for confirmation letters and billing statements)
Child’s ethnicity (check one):
____Asian/Pacific Islander
____ American Indian/Alaskan
____ White
____ African American/Black
____Hispanic/Latino
____Multiracial
Name(s) of other adults who may pick your child up from Safe Haven Summer Camp Program:
Name:
Relationship to child:
Phone #:___________
Name:
Relationship to child:
Phone #:___________
Please return completed forms and supporting paperwork to:
Safe Haven Summer Camp, Attention: Vicki, MNC 5740
Raymond Rd, Madison, WI 53711
SERVICES FOR PEOPLE WITH DISABLILITIES:
Please describe any medical condition or disability requiring accommodation to participate. To access Inclusion Services,
additional forms must be completed. Please contact Cheryl Dietrich 442-2970 (Lowell) and Kate Dvorak 204-3043
(Midvale). MSCR's Inclusion Services Coordinator, to request forms and discuss accommodations. At least two weeks
notification is required to plan and coordinate reasonable accommodations.
MEDICATION
Does your child require medication during the program?
No
Yes

If yes, authorization forms from you and your child’s doctor must be on file. Please ask the program supervisor
for medication forms. If your child self-administers over the counter or prescription medication, medication forms
must still be completed and on file at the program.
PAYMENT INFORMATION
CHECK ONE BOX BELOW THAT ACCURATELY REFLECTS HOW YOUR CHILD(S) SAFE HAVEN FEES
WILL BE PAID.
Please read through the following information completely before making your selection. If you have
questions regarding your child’s Safe Haven account, please call Vicki Mejeris at 467-8360 or
[email protected].

PAYING ALL FEES - Payment information will be emailed with your child’s confirmation letter.
Summer fees for the 8-week Safe
Haven program:
1
child
2 children from same
immediate family
3 or more children from same
immediate family
MMSD Resident Fees
$1120
$1960
$2800
Non Resident Fees, 50% more
$1680
$2940
$4200

QUALIFIED FOR WISCONSIN SHARES CHILDCARE ASSISTANCE AND HAVE ATTACHED THE
AUTHORIZATION NOTICE (please see procedure page). I agree to pay the parent share. You will be
billed what Dane County does not pay. Fee waivers are available only to MMSD residents.

APPLYING FOR MSCR PARTIAL FEE WAIVER AND HAVE ATTACHED THE WISCONSIN SHARES
DENIAL LETTER AND OTHER REQUIRED PAPERWORK VERIFYING MY INCOME (please see
procedure page). I agree to pay the bi monthly (twice a month) fees based on my income level as
determined by the sliding fee scale. Fee waivers are available only to MMSD residents.
DOES YOUR CHILD qualify for free or reduced school lunches?
Please return completed forms and supporting paperwork to:
No
Yes
Safe Haven Summer Camp, Attention: Vicki, MNC 5740
Raymond Rd, Madison, WI 53711
WAIVER AND RELEASE OF LIABILITY
By registering for MSCR youth programming, I hereby agree and understand:
1. That MSCR programs are not covered by accident insurance.
2. That I and my child(ren) will adhere to MSCR rules and procedures.
3. That I will hold the Madison Metropolitan School District (MMSD) harmless and defend the District against
any claims brought by and on behalf of my child(ren) for any injury sustained by my child(ren) as a result of
his/her participation in a MSCR program, provided, however, that this provision shall not apply to liabilities
caused by or resulting from the gross negligence of the District, it’s employees or agents.
4. That MMSD/MSCR staff may take photos of my child(ren) and I consent to the use of my child(ren)’s photo
for promotional or educational purposes.
5. That I hereby give permission for MSCR to take or transport my child(ren) on supervised field trips during
program hours.
6. That all children must leave the building at the close of the program. Parents/Guardians are responsible for
their children at closing time.
7. That I hereby grant permission for MMSD/MSCR staff to share, with each other, any information or records
regarding my child. This includes the ability of MMSD school staff to disclose to MSCR staff pupil records or
information related to disability status, health conditions and behavioral concerns for the purpose of providing
appropriate accommodations and supports in MSCR youth programming.
8. That MSCR/MMSD staff have my permission to assist my child in the application of sunscreen and/or insect
repellent prior to outdoor activities. It is my understanding that children are required to bring both sunscreen
and insect repellent for use during MSCR programs. Children should come to their program in the morning with
sunscreen already applied.
9. That if emergency medical care is deemed necessary and I am unable to be reached, MSCR staff is
authorized to act in my child’s behalf in granting permission for my child to receive emergency treatment or
surgery.
By registering or participating, the registrant understands that individual accident insurance is not
provided for MSCR programs and agrees to adhere to program rules. I do hereby, for myself, my
heirs, executors, and administrators, waive, release, and forever discharge any and all rights and
claims for damages that I may have or that may hereafter accrue to me arising out of or, in any way
connected with my participation in MSCR programs. Photos may be taken during program for
educational and marketing purposes. I have read and agree to follow the registration policies.
PARENT/GUARDIAN SIGNATURE:
Please return completed forms and supporting paperwork to:
DATE:
Safe Haven Summer Camp, Attention: Vicki, MNC 5740
Raymond Rd, Madison, WI 53711
MSCR Application for Financial Assistance
(Complete this form only if you are applying for a partial fee waiver)
Parent Name ___________________________________________________
Gender _____
Address ___________________________________________________________________________________________________
Street
City
Zip
Home Phone _________________Cell/Work Phone ________________ Emergency Phone ________________
Employer ____________________________________ Occupation ___________________________________
Daily work hours _____________________ Hours worked per week _______ Length of time employed ______
Single parent household ______ yes ______ no
Are you requesting assistance because you or a member of your immediate family has a disability? _____ yes _____ no
If yes, please explain the circumstances: ______________________________________________________________
__________________________________________________________________________________________
List all persons living in your household (including other adults):
Currently Employed
________________________________________ _____
Name:
Last
First
Middle Initial
___ ___________ _____ __________
Age Birthdate
Gender Relationship
Yes
No
________________________________________ _____
Name:
Last
First
Middle Initial
___ ___________ _____ __________
Age Birthdate
Gender Relationship
Yes
No
________________________________________ _____
Name:
Last
First
Middle Initial
___ ___________ _____ __________
Age Birthdate
Gender Relationship
Yes
No
________________________________________ _____
Name:
Last
First
Middle Initial
___ ___________ _____ __________
Age Birthdate
Gender Relationship
Yes
No
________________________________________ _____
Name:
Last
First
Middle Initial
___ ___________ _____ __________
Age Birthdate
Gender Relationship
Yes
No
(Any additional family members can be added to back of sheet.)
Why are you interested in having your child enrolled in the MSCR Safe Haven program? (please check one)
______ To provide childcare while I work
______ To provide childcare while I am in school ______ To provide a safe enriching
environment for my child______ Other: ______________________________________
Is your situation temporary (illness, loss of income, etc)? ______ yes ______ no
If so, when do you expect things to change? ______________________________________________________
Please explain any special circumstances or unusual expenses that you wish for us to consider ______________
__________________________________________________________________________________________
Please return completed forms and supporting paperwork to:
Safe Haven Summer Camp, Attention: Vicki, MNC 5740
Raymond Rd, Madison, WI 53711
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
dcf.wisconsin.gov
Child Enrollment and Health History – Certified Child Care
Use of form: Use of this form is voluntary. However, completion of this form meets the requirements of DCF 202.08(9)(d), 202.08(12)(f) and DCF 202.09(7)(b). If you are both certified
and licensed family child care, you are required to use the forms DCF-F-CFS0062 Child Care Enrollment and DCF-F-CFS2345 Health History and Emergency Care Plan. Failure to
comply with program regulations may result in the issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.
15.04(1)(m), Wisconsin Statutes].
Instructions – Parent / Guardian: The parent / guardian shall fill out the form completely, sign it and submit it to the certified provider prior to the child’s first day of attendance. Do not
leave any fields blank. If they do not apply, enter “N/A” or “none.” The parent / guardian should maintain ongoing communication with the child care to ensure the information on this
form is kept current. When enrolling a child under two years of age, a completed DCF-F-CFS0061-E Intake for Child Under 2 Years – Child Care Centers must also be on file prior to the
child’s first day of attendance.
Instructions – Child Care: The completed and signed form shall be obtained prior to the child’s first day of attendance, maintained in the child’s file on the premises, and available for
review by the regulating agency. Review the form to ensure that no fields have been left blank. Pay particular attention to the Birthdate and First Day of Attendance fields, and check to
ensure that the form has been signed by the parent and dated. The child care shall maintain a system of communication with the parent / guardian to ensure the information on this form
is kept current. A section is available at the end of this form where the child care may record the dates they reviewed or updated the information on the form. When enrolling a child
under two years of age, a completed DCF-F-CFS0061-E Intake for Child Under 2 Years – Child Care Centers must also be on file prior to the child’s first day of attendance.
A. CHILD INFORMATION
Name (Last, First, MI)
Address – Home (Street, City, Zip Code)
Birthdate (mm/dd/yyyy)
First Day of Attendance
Telephone Number
B. PARENT OR GUARDIAN – All parents / guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted by a court
order. Attach court order, if any.
Where Reachable While Child is in Care
Relationship
Name
Home Telephone
Cell Phone
to Child
Address (Street, City)
Telephone
Mother
Father
Guardian
Guardian
C. AUTHORIZED PERSONS – Persons other than parents / guardians who are authorized to pick up the child or accept the child if dropped off. If no one, write "None."
Where Reachable While Child is in Care
Relationship to Child
Name
Home Telephone
Cell Phone
Address (Street, City)
Telephone
DCF-F-DWSW13251-E (R. 04/2012)
Page 2 of 3
D. EMERGENCY CONTACT – The person to be notified in an emergency when parents / guardians cannot be reached.
Yes
No This person is authorized to pick up the child.
Relationship to Child
Name
E. PHYSICIAN OR MEDICAL FACILITY
Name
F.
1.
Home Telephone
Cell Phone
Where Reachable While Child is in Care
Address (Street, City)
Telephone
Address (Street, City, State, Zip Code)
Telephone Number
HEALTH HISTORY AND EMERGENCY CARE PLAN If available, attach any health care plan information from the child’s physician, therapist, etc.
Check any special medical condition that your child may have.
No specific medical condition
Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism
Asthma
Cerebral palsy / motor disorder
Diabetes
Epilepsy / seizure disorder
Gastrointestinal or feeding concerns including special diet and supplements. If the child has a medical condition, excluding food allergy, that requires a special diet including
nutrient concentrates and supplements, attach the written authorization from the child’s physician.
Milk allergy. If a child is allergic to milk, attach a statement from the medical professional indicating the acceptable alternative.
Food allergies – Specify food(s).
Non-food allergies – Specify.
Other condition(s) requiring special care – Specify.
2.
Triggers that may cause problems – Specify.
3.
Signs or symptoms to watch for – Specify.
DCF-F-DWSW13251-E (R. 04/2012)
Page 3 of 3
4.
Steps the child care provider should follow. If prescription or non-prescription medication is necessary, parental authorization is required and should be attached. The form
DCF-F-CFS0059-E Authorization to Administer Medication – Child Care Centers may be used by certified programs to comply with DCF 202.08(4)(f).
5.
When to call parents regarding symptoms or failure to respond to treatment.
6.
When to consider that the condition requires emergency medical care or reassessment.
7.
Additional information that may be helpful to the child care provider.
G. AUTHORIZATION – SUNSCREEN / INSECT REPELLENT – If provided by the parent / guardian, the sunscreen or insect repellent shall be labeled with the child’s name.
Authorizations shall be reviewed periodically and updated as necessary.
Brand Name
Ingredient Strength
Yes
No
I authorize the center to apply sunscreen to my child.
Yes
No
I authorize the center to allow my child to self-apply sunscreen.
Yes
Yes
No
No
I authorize the center to apply repellent to my child.
I authorize the center to allow my child to self-apply repellent.
Brand Name
Ingredient Strength
H. AUTHORIZATION – EMERGENCY MEDICAL TREATMENT
Yes
No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.
I. AUTHORIZATION – FIELD TRIPS / TRANSPORTATION
Yes
No I give permission for my child to be transported to and from the center.
Yes
No I give permission for my child to participate in field trips and other activities during operating hours.
Transported
Walking
Yes
No I hereby give permission for my school-aged child to enter a building unescorted.
J. ATTESTATION
Yes
No I have had an opportunity to review the policies of this child care center and a summary of the Wisconsin rules, DCF 202, governing certified child care
programs.
Yes
No I have been informed of the number of pets in the center and their degree of contact with the enrolled children. Note: If pets are added after a child is enrolled,
parents shall be notified in writing prior to the pet'
s addition to the center.
K. SIGNATURE
Date Signed
SIGNATURE – Parent or Guardian
Review dates:
DCF-F-DWSW13251-E (R. 04/2012)
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-44192 (Rev. 09/08)
STATE OF WISCONSIN
ss. 252.04,Wis. Stats.
DAY CARE IMMUNIZATION RECORD
COMPLETE AND RETURN TO DAY CARE CENTER . State law requires all children in day care centers to present evidence of immunization against certain
diseases within 30 school days (6 calendar weeks) of admission to the day care center. These requirements can be waived only if a properly signed
health, religious, or personal conviction waiver is filed with the day care center. See “Waivers” below. If you have any questions on immunizations or how to
complete this form, please contact your child’s day care provider or your local health department.
PERSONAL DATA
STEP 1
PLEASE PRINT
Child’s Name(Last, First, Middle Initial)
Date of Birth (Month/Day/Year)
Area Code/Telephone Number
Name of Parent/Guardian/Legal Custodian (Last, First, Middle Initial)
Address (Street, Apartment number, City, State, Zip)
IMMUNIZATION HISTORY
STEP 2
List the MONTH, DAY AND YEAR the child received each of the following immunizations. DO NOT USE A (4) OR (X) except to indicate whether
the child has had chickenpox. If you do not have an immunization record for this child, contact your doctor or local public health department to
obtain the records.
TYPE OF VACCINE
First Dose
Second Dose
Third Dose
Fourth Dose
Fifth Dose
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Diphtheria-Tetanus-Pertussis
(Specify DTP, DTaP, or DT)
Polio
Hib (Haemophilus Influenzae Type B)
Pneumococcal Conjugate Vaccine (PCV)
Hepatitis B
Measles-Mumps-Rubella (MMR)
Varicella (chickenpox) vaccine
Vaccine is required only if the child has
not had chickenpox disease.
Has the child had Varicella (chickenpox) disease? Check the appropriate box and provide the year if known.
Yes year _____________________ (Vaccine is not required)
No or Unsure (Vaccine is required)
REQUIREMENTS
STEP 3
The following are the minimum required immunizations for the child’s age/grade at entry. All children within the range must meet these
requirements at day care entrance. Children who reach a new age/grade level while attending this day care must have their records updated with
dates of additional required doses.
AGE LEVELS
NUMBER OF DOSES
5 months through 15 months
2 DTP/DTaP/DT
2 Polio
2 Hib
2 PCV
2 Hep B
1
2
3
16 months through 23 months
3 DTP/DTaP/DT
2 Polio
3 Hib
3 PCV
2 Hep B
1 MMR
1
2
3
2 years through 4 years
4 DTP/DTaP/DT
3 Polio
3 Hib
3 PCV
3 Hep B
1 MMR
1 Varicella
4
3
At Kindergarten entrance
4 DTP/DTaP/DT
4 Polio
3 Hep B
2 MMR
2 Varicella
1
If the child began the Hib series at 12-14 months of age, only 2 doses are required. If the child received one dose of Hib at 15 months of age or
after, no additional doses are required. Minimum of one dose must be received after 12 months of age (Note: a dose 4 days or less before the
first birthday is also acceptable).
2
If the child began the PCV series at 12-23 months of age, only 2 doses are required. If the child received the first dose of PCV at 24 months of
age or after, no additional doses are required.
3
st
MMR vaccine must have been received on or after the first birthday (Note: a dose 4 days or less before the 1 birthday is also acceptable).
4
th
rd
th
th
Children entering kindergarten must have received one dose after the 4 birthday (either the 3 , 4 or 5 ) to be compliant (Note: a dose 4 days or
th
less before the 4 birthday is also acceptable).
COMPLIANCE DATA AND WAIVERS
STEP 4
IF THE CHILD MEETS ALL REQUIREMENTS (sign at STEP 5 and return this form to the day care center), OR
IF THE CHILD DOES NOT MEET ALL REQUIREMENTS (check the appropriate box below, sign and return this form to day care center).
Although the child has not received all required doses of vaccine for his or her age group, at least the first dose of each vaccine has been
received. I understand that it is my responsibility to obtain the remaining required doses of vaccines for this child WITHIN ONE YEAR and to
notify the day care center in writing as each dose is received.
NOTE: Failure to stay on schedule or report immunizations to the day care center may result in court action against the parents and a
fine of up to $25.00 per day of violation.
For health reasons this child should not receive the following immunizations __________(List in STEP 2 any immunizations already received)
______________________________________________________________________
Physician’s Signature Required
For religious reasons this child should not be immunized. (List in STEP 2 any immunizations already received)
For personal conviction reasons this child should not be immunized. (List in STEP 2 any immunizations already received):
SIGNATURE
STEP 5
To the best of my knowledge this form is complete and accurate.
____________________________________________________________________________
______________________________________
SIGNATURE - Parent, Guardian or Legal Custodian
Date Signed
Clear Form and Reset
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
dcf.wisconsin.gov/
CHILD HEALTH REPORT – CHILD CARE CENTERS
Use of form: Use of this form is voluntary; however, completion of this form meets the requirements of DCF 202.08(4), DCF 250.07(6)(L)3.,
and DCF 251.07(6)(k)3. Failure to comply with these rules may result in issuance of a noncompliance statement. Personal information
you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: Each child under 2 years of age shall have an initial health examination not more than 6 months prior to nor later than 3
months after being admitted to the center and a follow-up health examination at least once every 6 months thereafter. Except for a schoolaged child, each child 2 years of age or older shall have an initial health examination not more than one year prior to nor later than 3 months
after being admitted to a center and a follow-up health examination at least once every 2 years thereafter. The parent / guardian shall give
this form to the physician, physician assistant or HealthCheck provider to be completed, signed and dated. The licensee shall obtain a copy
for the child’s record. Note: Children are also required to have on file at the child care center documentation of immunizations; it may be
helpful if the parent / guardian were to include a copy of the child’s immunization record when submitting this form to the child care center.
PARENT OR GUARDIAN – Complete this section.
Name – Child (Last, First, MI)
Birthdate – Child (mm/dd/yyyy)
Address – Child (Street, City, State, Zip Code)
Name – Parent or Guardian (Last, First, MI)
Address – Parent or Guardian (Street, City, State, Zip Code)
HEALTH PROFESSIONAL – Complete this section.
Instructions for feeding and care of child with special problems, including allergies – Specify (attach information as necessary).
Yes
No Does the child have a milk allergy? If “Yes”, identify the recommended milk substitute.
Date of most recent blood lead test:
(mm/dd/yyyy). Note: Children on Medicaid are required to be tested at
around ages 12 months and 24 months or once between the ages of 3 and 5 years if no previous test is documented. Lead testing is
optional for children who are not on Medicaid.
Immunization(s) not to be administered to child due to medical reason(s) – Specify.
AUTHORIZATION
I certify that I have examined the above child on this date and that he / she is able to participate in child care activities.
Name – MD, PA or HealthCheck Provider (type or print)
SIGNATURE – MD, PA or HealthCheck Provider
DCF-F-CFS0060-E (R. 07/2013)
Address (Street, City, State, Zip Code)
Date of Examination