Arrangements for Short Term Care
I certify that all immunizations are up-to-date for polio, rubella, diphtheria, tetanus, pertussis, measles, mumps,
haemophilus influenza, varicella (chicken pox), and pneumococcal conjugate.
I give permission for my child(ren) to be transported by car, bus, rapid transit, and other public transportation.
While in a car age appropriate restraint systems must be used.
I give permission for the use of insect repellent, sun screen and sun block, topical first aid preparations, topical
analgesics, and diaper ointment and powder.
I give permission for the day care to arrange and authorize emergency medical care for my child(ren) in the event
that I cannot be reached, including but not limited to stitches,
setting bones, burn treatment, and surgery, if the
delay of such treatment might hinder healing or cause additional trauma or pain.
I understand that the day care does have pets in the residence.
I understand that smoking is not allowed.
I understand that there are substitutes and helpers employed in the day care, and parent volunteers present, who will
be working with the children from time to time without additional or separate notice.
I understand that food or diapers brought from home must be labeled with the child(ren)’s name(s).
I understand that I am required to notify the day care within 24 hours of the diagnosis of a contagious illness or
parasitic infestation, that the day care is required to notify me if my
child has been exposed, and that the day
care is required to report certain illnesses, parasites, or suspected abuse to the proper authorities.
(List of reportable illnesses is available at day care.)
I understand that written information is available on ages and numbers of children in care, on nondiscrimination
practices, on fire and storm plans and drills, on licensing
regulations, and on the day care policies for fees and
I understand that regular day care activities include outdoor play, field trips, lessons, and special events in which
my child may be included without further and specific notice to
the parent, including but not limited to walks,
trips to various parks and nature centers, sledding, swimming, skating,
other sports, horse back riding, movies,
Write notations in text above or note space below to make these arrangements apply to you and your child.
_______________________________ _______________________________ ______________________
– parent or