Family Child Care Admission and Arrangements
PLEASE PRINT. Complete one form for each child in care. This form must be kept on file at the family child care home. Please Note: Pursuant to
MN Rules. 9502.0405, subpart 4, the provider shall obtain the required information for each child prior to admission.
The licensed child care provider completes items 1, 8, & 9 prior to the parent/guardian completing the rest of the form. Both parties sign the form when completed.
The information requested will be maintained in a private manner and will not be released to anyone other than the licensing consultant without your prior written
approval.
1. NAME OF CHILD CARE PROVIDER(S) (LAST, FIRST, MIDDLE)
2. CHILD’S NAME (LAST, FIRST, MIDDLE)
NAME OF SUPERVISING AGENCY
5. RESPONSIBLE FRIEND/RELATIVE TO CALL IF PARENTS CANNOT
BE REACHED
6. NAMES OF ALL PERSONS AUTHORIZED TO REMOVE THE
CHILD FROM THE HOME
7. EMERGENCY CONTACT INFORMATION FOR CHILD
HOSPITAL TO BE USED FOR EMERGENCIES
NAME OF PARENT’S MEDICAL INSURANCE COMPANY
IF UNAVAILABLE, ANOTHER LICENSED PHYSICIAN MAY TREAT MY CHILD YES NO
NAME OF PARENT’S DENTAL INSURANCE COMPANY
IF UNAVAILABLE, ANOTHER LICENSED DENTIST MAY TREAT MY CHILD YES NO
SERVICES PROVIDED (INCLUDING DAYS, HOURS, MEALS ETC.)
SPECIAL CONDITIONS (SPECIAL DIET, SPECIAL NEEDS, ALLERGIES)
9. LIABILITY INSURANCE NOTIFICATION:
Pursuant to 245A.152 (a) A license holder must provide a written notice to all parents or guardians of all children to be accepted for care prior to
admission stating whether the license holder has liability insurance. This notice may be incorporated into and provided on the admission form
used by the license holder. Check one below
I do have liability insurance. A current certificate of coverage of insurance is available for inspection to all parents/guardians of children receiving
services and to all parents seeking services from the family child care program. My policy will expire on (month/day/year) _________________________.
I do not have liability insurance.
AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN ITEM 1 ABOVE, TO OBTAIN EMERGENCY
MEDICAL CARE OR TREATMENT IN THE EVENT OF AN EMERGENCY
YES NO
AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN ITEM 1 ABOVE, TO PROVIDE
TRANSPORTATION TO MY CHILD
YES NO
AUTHORIZATION: We the undersigned hereby agree to abide by the arrangements and authorizations so stated above. We have discussed the information
required in the rule part 9502.0405.
SIGNATURE OF CHILD CARE PROVIDER
SIGNATURE OF PARENT/ GUARDIAN
November 2013