Form MO580-2994 "Child Care Enrollment Form" - Missouri

What Is Form MO580-2994?

This is a legal form that was released by the Missouri Department of Health and Senior Services - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the Missouri Department of Health and Senior Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO580-2994 by clicking the link below or browse more documents and templates provided by the Missouri Department of Health and Senior Services.

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Download Form MO580-2994 "Child Care Enrollment Form" - Missouri

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION/BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE
CHILD CARE ENROLLMENT FORM
FACILITY/PROVIDER NAME
ADMISSION DATE
DISCHARGE DATE
CHILD’S NAME
GENDER
BIRTHDATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S/GUARDIAN’S NAME
TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF THE SAME AS ABOVE
E-MAIL ADDRESS
EMPLOYER OR SCHOOL
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
FATHER’S/GUARDIAN’S NAME
TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF THE SAME AS ABOVE
E-MAIL ADDRESS
EMPLOYER OR SCHOOL
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBER(S)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBER(S)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
COMMENTS ON CHILD’S DEVELOPMENT
(PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS)
RELATED CHILD
HOW IS CHILD RELATED TO CHILD CARE PROVIDER
Yes
No
CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED
CHECK HERE WHAT DAYS THE
CHILD WILL ATTEND.
WHAT TIME DOES YOUR CHILD
WHAT TIME DOES YOUR CHILD
WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL
WILL CHILD ATTEND:
USUALLY ARRIVE EACH DAY?
USUALLY LEAVE EACH DAY?
ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES
Full Time
Part Time
MONDAY
AM
PM
AM
PM
TUESDAY
AM
PM
AM
PM
WEDNESDAY
AM
PM
AM
PM
THURSDAY
AM
PM
AM
PM
FRIDAY
AM
PM
AM
PM
SATURDAY
AM
PM
AM
PM
SUNDAY
AM
PM
AM
PM
MO 580-2994 (10-2020)
Page 1 of 3
SCCR/CACFP
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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
SECTION FOR CHILD CARE REGULATION/BUREAU OF COMMUNITY FOOD & NUTRITION ASSISTANCE
CHILD CARE ENROLLMENT FORM
FACILITY/PROVIDER NAME
ADMISSION DATE
DISCHARGE DATE
CHILD’S NAME
GENDER
BIRTHDATE
ADDRESS (STREET, CITY, STATE, ZIP CODE)
IDENTIFYING INFORMATION
MOTHER’S/GUARDIAN’S NAME
TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF THE SAME AS ABOVE
E-MAIL ADDRESS
EMPLOYER OR SCHOOL
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
FATHER’S/GUARDIAN’S NAME
TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE) OR CHECK IF THE SAME AS ABOVE
E-MAIL ADDRESS
EMPLOYER OR SCHOOL
WORK/SCHOOL SCHEDULE
EMPLOYER/SCHOOL ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY
(OTHER THAN PARENT) AT LEAST ONE EMERGENCY CONTACT IS REQUIRED.
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBER(S)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
NAME
RELATIONSHIP TO CHILD
TELEPHONE NUMBER(S)
ADDRESS (STREET, CITY, STATE, ZIP CODE)
COMMENTS ON CHILD’S DEVELOPMENT
(PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS, HABITS, & INDIVIDUAL NEEDS)
RELATED CHILD
HOW IS CHILD RELATED TO CHILD CARE PROVIDER
Yes
No
CHILD’S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATIONS EXPECTED
CHECK HERE WHAT DAYS THE
CHILD WILL ATTEND.
WHAT TIME DOES YOUR CHILD
WHAT TIME DOES YOUR CHILD
WRITE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL
WILL CHILD ATTEND:
USUALLY ARRIVE EACH DAY?
USUALLY LEAVE EACH DAY?
ATTENDANCE IN THIS SECTION INCLUDING SHIFT CHANGES
Full Time
Part Time
MONDAY
AM
PM
AM
PM
TUESDAY
AM
PM
AM
PM
WEDNESDAY
AM
PM
AM
PM
THURSDAY
AM
PM
AM
PM
FRIDAY
AM
PM
AM
PM
SATURDAY
AM
PM
AM
PM
SUNDAY
AM
PM
AM
PM
MO 580-2994 (10-2020)
Page 1 of 3
SCCR/CACFP
CHECK THE MEALS YOUR CHILD IS USUALLY GIVEN AT THIS FACILITY
BREAKFAST
MORNING SNACK
LUNCH
AFTERNOON SNACK
SUPPER
EVENING SNACK
NONE
CHECK THE HOLIDAYS YOUR CHILD IS IN CARE AT THIS FACILITY
NEW YEARS’S DAY
MARTIN LUTHER KING JR.’S
PRESIDENT’S DAY
EASTER (MARCH/APRIL)
(JANUARY)
BIRTHDAY (JANUARY)
(FEBRUARY)
MEMORIAL DAY (MAY)
INDEPENDENCE DAY (JULY)
LABOR DAY (SEPTEMBER)
COLUMBUS DAY (OCTOBER)
VETERANS DAY
ELECTION DAY (NOVEMBER)
THANKSGIVING
CHRISTMAS DAY
(NOVEMBER)
(NOVEMBER)
(DECEMBER)
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE OF AN EMERGENCY WITH MY CHILD, AND I WILL MAKE ARRANGE-
MENTS FOR MEDICAL CARE OF MY CHILD WITH THE PHYSICIAN OR HOSPITAL OF MY CHOICE.
IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL
CARE, I AUTHORIZE
(LIST CHILDCARE FACILITY NAME HERE)
TO CONTACT THE FOLLOWING:
PHYSICIAN OR CLINIC
NAME
TELEPHONE NUMBER
PREFERRED HOSPITAL
NAME
TELEPHONE NUMBER
ACKNOWLEDGMENTS
I HAVE RECEIVED A COPY OF THIS FACILITY’S POLICIES PERTAINING TO THE ADMISSION, CARE AND
PARENT/GUARDIAN INITIALS
A
DISCHARGE OF CHILDREN.
I HAVE BEEN INFORMED THAT A COPY OF THE LICENSING RULES FOR CHILD CARE HOME OR THE
PARENT/GUARDIAN INITIALS
B
LICENSING RULES FOR GROUP CHILD CARE HOMES AND CENTERS IS AVAILABLE AT THIS FACILITY
FOR REVIEW
THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY
PARENT/GUARDIAN INITIALS
C
CHILD’S DEVELOPMENT, BEHAVIOR, AND INDIVIDUAL NEEDS.
WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR
PARENT/GUARDIAN INITIALS
D
REMAIN IN CARE.
I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE PROOF
PARENT/GUARDIAN INITIALS
E
OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS.
I
DO
DO NOT GIVE PERMISSION FOR FIELD TRIPS/EXCURSIONS. I UNDERSTAND I WILL BE
PARENT/GUARDIAN INITIALS
F
NOTIFIED IN ADVANCE WHEN THEY ARE PLANNED.
PARENT/GUARDIAN INITIALS
G
I
DO
DO NOT GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD.
I HAVE BEEN INFORMED AND HAVE RECEIVED A COPY OF THE FACILITY’S SAFE SLEEP POLICY WHEN
PARENT/GUARDIAN INITIALS
H
ENROLLING A CHILD LESS THAN ONE (1) YEAR OF AGE.
I HAVE BEEN NOTIFIED THAT I MAY REQUEST NOTICE AT INITIAL ENROLLMENT OR ANY TIME THERE
PARENT/GUARDIAN INITIALS
I
AFTER WHETHER THERE ARE CHILDREN CURRENTLY ENROLLED IN OR ATTENDING THE FACILITY FOR
WHOM AN IMMUNIZATION EXEMPTION HAS BEEN FILED.
PARENT’S/GUARDIAN’S SIGNATURE
DATE
FIRST ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
SECOND ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
THIRD ANNUAL UPDATE
PARENT/GUARDIAN SIGNATURE
DATE
MO 580-2994 (10-2020)
Page 2 of 3
SCCR/CACFP
USDA Nondiscrimination Statement
For all other FNS nutrition assistance programs, State or local agencies, and their subrecipients, must post the following Nondiscrimination
Statement:
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participation in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard
of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program
information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at
https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complain, and at any USDA office, or write a letter addressed to USDA
and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter 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;
(2)
Fax: (202) 690-7442; or
(3)
Email: program.intake@usda.gov.
This institution is an equal opportunity provider.
MO 580-2994 (10-2020)
Page 3 of 3
SCCR/CACFP
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