Clear Form

*DHS-7776-ENG*
DHS-7776-ENG 9-19

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 and keep the information
up to date.
CHILD INFORMATION
Last Name First Name Birthdate (mm/dd/yyyy) Date Enrolled in Care

Address City State Zip Code

PARENT OR GUARDIAN # 1
Last Name First Name Place of Employment and Work Phone No.

Address of Employer City State Zip Code

Email Home Phone Cell Phone

Address (if different from child) City State Zip Code

PARENT OR GUARDIAN # 2
Last Name First Name Place of Employment and Work Phone No.

Address of Employer City State Zip Code

Email Home Phone Cell Phone

Address (if different from child) City State Zip Code

EMERGENCY CONTACT FOR CHILD IF PARENTS CAN’T BE REACHED One Contact Required
Last Name First Name Relationship and Phone Number

Address City State By checking I am authorizing

this person to pick up my child

Last Name First Name Relationship and Phone Number

Address City State By checking I am authorizing

this person to pick up my child

Last Name First Name Relationship and Phone Number

Address City State By checking I am authorizing

this person to pick up my child

EMERGENCY INFORMATION FOR CHILD

Hospital to be used for emergencies Physician’s Name Telephone

Address City State Zip Code

Dentist to be used for emergencies Dentist’s Name Telephone If you don’t have a dentist yet for
your child, check this box

Address City State Zip Code

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CHILD CARE PROVIDER
Name License #

Address City State Zip Code

ARRANGEMENTS
Financial Arrangements

Services Provided (Including Days, Hours, Meals, Etc.)

Special Conditions ( Special Diet, Special Needs)

Does Your Child Have Allergies YES NO NOTE: If Yes, Complete the Allergy Information Form

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. Select one of the options below.
I do have liability insurance. A current certificate of coverage of insurance is available for inspection to all parents and guardians of
children receiving services and to all parents seeking services from the family child care program. The expiration date is:

I do not have liability insurance

PERMISSIONS
AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN THE ITEM ABOVE, TO PROVIDE TRANSPORTATION FOR MY CHILD
Yes No

ANY SPECIAL TRAVEL ARRANGEMENTS

I have received a copy of the maltreatment of minors mandated reporter policy

AUTHORIZATION IS HEREBY GIVEN TO THE CHILD CARE PROVIDER AS NAMED IN THE ITEM ABOVE, TO OBTAIN EMERGENCY MEDICAL CARE OR
TREATMENT IN THE EVENT OF AN EMERGENCY Yes No
AUTHORIZATION: We the undersigner hereby agree to abide by the arangements and authorizations so stated above. We have discussed the
information required in the rule part 9502.0405

Signature of Child Care Provider Date

Signature of Parent / Guardian Date

Signature of Parent / Guardian Date

Updated
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