| Emergency Contact Information |
Note: This form will be submitted electronically.
* Required Fields
Date:
* Name of Child:
* Birth Date:
(mm/dd/yyyy)
* Address:
* City:
* Contact Phone:
(937) 000-0000) |
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* Allergies
Yes
No
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If Yes, List Allergies:
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If Yes, you must fill out the Child Medical/Physical Care Plan, JFS 01236.
This form is required by the Ohio Department of Job and Family Services.
It is available in MS Word format and in PDF format.
It must be printed, completed, and signed by the parent, administrator, and trained staff before the child's first day of school. It is due prior to your child's first day of school..
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| Fill in all required fields. If field does not apply, type N/A. |
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* Name of Mother:
* Home Phone:
* Cell Phone:
* Employer:
* Work Phone:
* Mother Works:
Yes
No
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| Fill in all required fields. If field does not apply, type N/A |
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* Name of Father:
* Home Phone:
* Cell Phone:
* Employer:
* Work Phone:
* Father Works:
Yes
No |
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| Fill in all required fields. If field does not apply, type N/A |
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* Name of Guardian:
* Home Phone:
* Cell Phone:
* Employer:
* Work Phone:
*Â Guardian Works:
Yes
No
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In Case Of Emergency Contact/Authorized To Pick Up
The primary caregiver for the child cannot be listed as an emergency contact.
* List the names of at least three (3) people who can be reached in the event of an emergency or illness if you (the primary caregiver) cannot be reached.
Any person listed must::
- be able to assist the Center in contacting you
- be at least 1/2 hour from the Center
- take responsibility for the child in case you cannot be contacted
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