2019/20PreschoolEnrollmentPacketDirectionsforCompletingForms

Now,foryourhomework:Toaidusinmeetingyourchild’sneeds,andtobeabletogeneratethereportsthatarerequiredbyourStateExaminertostartourschoolyear,pleasefax,mailordropoffthefollowingformstousbyThursday,August1.Pleaseletmeknowifyouwouldprefertopickupapacketorhaveonemailedtoyou.

Tosavepaper,thispackethasbeenspecificallydesignedtoprintdouble‐sided;wewouldappreciateyoursupportinourCenter’sgreeninitiatives.

Everyonemustsubmitbothsidesof#1‐8.1. SchlitzAudubonNaturePreschoolContactInformation2. ChildInformationForm3. ExpectationsforAdults4. EnrollmentAgreement5. HealthHistoryandEmergencyCarePlan6. Tuitionpayment(fullyear,semesterormonthlyoptions)7. ChildHealthReport‐mustbesignedbyyourDoctor.Ahealthexammustbedonenotmore

thanoneyearpriorto,nor3monthslaterthan,startingPreschool8. Immunizationrecord–Required.Youhavetwochoices:

a) ifyourchildisuptodate,youcanhaveyourchild’spediatricianfaxtheimmunizationrecordto414‐352‐6091attention:LaurieL,b) IfyouhaveoptedoutofsomeoralloftherequiredimmunizationspleaseprintofftheStudentImmunizationRecord,checktheappropriateboxes,signanddateit.

Ifmedicationswillbeleftwithus,thisformmustbecompletedandputinaplasticziplockbagalongwiththemedications.Medicationsmustincludeaprescriptionlabelandbewithindate.

9. AuthorizationtoAdministerMedication

Schlitz Audubon Nature Preschool Contact Information 2019/20

Child's Name Gender ________ Age ________ Date of Birth

Parents or Guardians ________________________________________________________ If Guardian, relationship to Child ____________________________ Child resides with ____________________

Family Status: Married _____ Separated _____ Divorced _____ Single _____ Widowed _____ First day of attendance__________________________

Street Address ___________________________________________________ City _________________________________________ Zip Code ________________

Please provide email addresses to be used only for communication from Schlitz Audubon Nature Preschool - it is kept confidential. All Preschool correspondence will be sent to you by email – check regularly.

____________________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________

Primary person to contact during school hours

Name ________________________________________________________

Relationship _______________________________________________

Cell phone ______________________________ Work phone _________________________________

Secondary person to contact during school hours

Name _________________________________________________________

Relationship __________________________________________________

Cell phone ___________________________________ Work phone ______________________________

Parent Address (if different than above)

Name

Address _____

City, Zip_________________________________________________________________

Emergency contact – The person to be notified in an emergency when parents/guardians cannot be reached. They are authorized to pick up child.

Name and Relationship to Child _________

Phone # where reachable when child is in school ________________________________________

Place of employment and work phone # ___________________________________________________

In addition to parents, persons authorized to pick up child: (Please indicate if 'NONE')

#1 Name and Relationship to Child ________

Phone # where reachable when child is in school _______________________________________

Place of employment and work phone # _________________________________________________

#2 Name and Relationship to Child ________

Phone # where reachable when child is in school _______________________________________

Place of employment and work phone # __________________________________________________

#3 Name and Relationship to Child ________

Phone # where reachable when child is in school _______________________________________

Place of employment and work phone # _________________________________________________

Physician or medical facility:

Name

Address

City, Zip____________________________________ Phone _________________________________

Signature of Parent/Guardian Date:

Schlitz Audubon Nature Preschool Child Information Form 2019/20

Please fill out this form as completely as possible. This information will assist us in getting to know your child better and making him/her feel comfortable at our preschool. This information will be kept in your child’s file and is confidential.

Child’s Full Name: Birthdate: / /20 What name would you like us to call your child: Parents’/Guardians’ Names: What languages are spoken in the home? Health History: Significant Events (Prenatal, Birth, Early Development):

Sleep Patterns (Nap? How many hours usually at night?):

Social/Emotional Traumatic Events:

Fears or Apprehensions:

Child’s reaction, behavior when… Sad: Angry: Scared: Describe Child’s Temperament:

Does your child have an IEP (Individualized Education Plan)?

Has your child been evaluated for speech? Currently in speech program?

Do you have concerns about your child’s speech?

Has your child been in group care before? Describe:

Currently attending another school? Where? Days? Times?

Family Who usually cares for child at home? Any other adults in home? Siblings (name/age gender):

PLEASE COMPLETE THE SECOND SIDE

Relationship with siblings:

Significant familial experience (recent move, visit from relatives, new pets, etc.):

What discipline methods are used at home?

Child’s Preferences What experience/interest does your child have with nature and outdoor activities?

Favorite Activities:

How does your child learn best?

Self Help What will he/she need help with at school?

What words/actions does your child use to indicate the need to use the bathroom?

Parent Do you have any concerns about your child’s school experience?

What are your hopes and dreams for your child?

What else would you like us to know about your child?

Parent vocation/place of employment: Mom: Dad: Do you have an interest in sharing your work, hobbies, or cultural traditions with your child’s class? If yes, please let us know what that would be and how often.

Are you interested in volunteering in your child’s classroom? If yes, please indicate your availability.

Please keep us informed of any changes in your child’s life!

2019/20 Expectations for Adults

Our goal at Schlitz Audubon Nature Preschool is to create an environment in which everyone is

able to achieve their best in an atmosphere of kindness, understanding and respect. The

following is an outline of expectations for the adults in our school community who work

together in support of the children.

We expect everyone to:

Treat one another with courtesy

Set good examples for children in terms of speech and behavior

Go through the proper channels of communication when problems arise (this includes

talking first with teachers regarding any classroom concerns, then with the Preschool

Director and/or the Preschool Coordinator, and finally, if needed, the Executive Director

of the Center)

Maintain confidentiality

Follow school rules, deadlines, and calendars

Read all school communications, including emails, calendars, and handbooks

Arrive and pick-up children on time / start and end class on time

Parents and caregivers are expected to supervise their children in the building and while

playing on school grounds both before drop-off and after pick-up

Teachers and volunteers are expected to use developmentally appropriate practice

Social Media Policy

We expect our entire preschool community to abide by the following rules regarding social

media.

Do not share confidential information, internal school discussions, or personal and

specific information about students, parents, teachers, or staff on social media sites.

Do not post photos that identify any of our preschool children by name and by

classroom without prior permission from that child’s parents or guardians.

Please understand that some teachers and staff prefer not to accept social media

friendship requests from parents while their child is enrolled in preschool. This is a

professional choice and should not be taken personally.

2019/20 Enrollment Agreement

1. I understand that per Wisconsin State licensing regulations, my child must be fully toilettrained to attend Nature Preschool.

By “fully toilet trained” we mean that your child must wear underpants, not pull-ups, and be able to urinate and have their bowel movement on the toilet as well as wipe themselves after. We understand that there may be “one-off” accidents, but if a child is having toileting accidents in preschool on a regular basis, we do not consider that child to be fully toilet trained.

2. I understand that if my child has a toileting accident at school, the teachers will do theirvery best to assist my child with cleaning and changing clothes. I may receive a phonecall alerting me that my child has had a toileting accident. I also understand that thepreschool is not licensed to change diapers and does not have the facilities needed tofully clean or bathe a child following a toileting accident.

3. I agree to call the Nature Preschool program if my child will not be attending school on aregularly scheduled day. Please do not text or email to report a student absence.

4. I understand that the Nature Preschool staff will assume full responsibility for my childfrom the time she/he arrives and is signed in, until the time when she/he is signed outupon departure by a parent or authorized person.

5. I am aware of the hours of operation and agree to pick up my child promptly. Iunderstand that I will be assessed a $2.00 per minute late pick up charge if I amregularly more than 5 minutes late picking up my child.

6. I give my child permission to participate fully in this program. This includes visits toother rooms in the Nature Center building, such as the Hearth Room, Auditorium, etc. Italso includes hiking on the 6 miles of trails, visiting the shores of Lake Michigan andponds within the 185 acres of our Nature Center.

7. I hereby give my consent for emergency medical care/treatment to be used if I cannotbe reached immediately.

I hereby give my consent for staff to use a Preschool-prescribed epi-pen should my child experience signs of anaphylactic shock due to a previously unknown allergy.

Yes No

8. I understand that I must apply sunscreen and/or repellent to my child prior to drop-off.The Nature Preschool does not apply these products without medical authorization.

9. I give permission for my child to be interviewed/photographed/videoed foreducational/Schlitz Audubon marketing purposes (please circle). Yes No

I am comfortable with my child’s image appearing on Facebook, with the understanding that my child will not be identified by name (please circle). Yes No

10. I have had an opportunity to review the nature preschool’s Parent Handbook along withthe Wisconsin Licensing Rules for Group Child Care Centers. The Parent Handbookincludes information pertaining to illness, discipline, inclement weather, emergencies,insects, outside snacks, allergies, and parent engagement. (This information is posted inthe Preschool hallway. The Parent Handbook is also available on our web page.)

(signed) ______________________________________________ Date __________

Schlitz Audubon Nature Center

Attn: Laurie Lukaszewicz

1111 East Brown Deer Road

Milwaukee, WI 53217

(414) 352-2880

llukas@schlitzaudubon.org

2019/20 Schlitz Audubon Nature Preschool Tuition Statement

Families who registered during the initial Registration process should have already paid the following fees. There will be a check mark if you have not yet paid these amounts:

⍜$35 non-refundable Application Fee (for each child) ⍜ $250 non-refundable Deposit per child (applied towards tuition as outlined below)

Full Year Tuition Payment - Your $250 Deposit and a 3% discount on 2nd semester tuition have been subtracted from the total tuition. Due Aug. 1 _____ 2 Days $2,610 _____ 3 Days $3,695 _____ 4 Days $4,440

Semi-Annual Payments - Your $250 Deposit has been subtracted from the second semester tuition. Due Aug. 1 _____ 2 Days $1,448 _____ 3 Days $1,999 _____ 4 Days $2,377 Due Dec. 1 _____ 2 Days $1,198 _____ 3 Days $1,749 _____ 4 Days $2,127

Total payments 2 Days $2,646 3 Days $3,748 4 Days $4,504

Monthly Payments – Your $250 Deposit is applied evenly over 9 payments. We require your charge card (MasterCard, Visa, Amex or Discover) to be on file. A 2.5% service charge & 5% financing fee has been added.

Charged on the 1st business day of each month – August thru April _____ 2 Days $302 _____ 3 Days $427 _____ 4 Days $514

Total of these payments 2 Days $2,718 3 Days $3,843 4 Days $4,626

After School Extension program - available for children in afternoon classes only. $380 per semester. Due Aug. 1- First semester payment ____ $400 Due Dec. 1- Second semester payment ____ $400

Please note that a $25 late fee will be assessed for those missing the tuition due dates.

_______________________________________________________________________ authorize the following tuition payment for ___________________________________________________________. (Parent’s name for membership card) (Child’s name)

Check enclosed $__________________________ Please make check payable to: Schlitz Audubon Nature Center.

Credit Card: please note that we accept MasterCard, Visa, Amex and Discover. Amount to be charged $___________________________

_______________________________________________________________________________________ __________________________________ ____________________________ ______________________ Account number Expiration Date CVV code Zip Code

Signature _______________________________________________________________ Parent’s Name Printed _________________________________________________________________________

DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-2345) (R. 03/2009)

STATE OF WISCONSIN

Page 1 of 2

HEALTH HISTORY AND EMERGENCY CARE PLAN Use of form: This form is required for family and group child care centers and day camps to comply with DCF 250.04(6)(a)1. and 250.07(6)(L)5., DCF 251.04(6)(a)6. and 251.07(6)(k)5.,

and DCF 252.44(6)(g) of the Wisconsin Administrative Codes. Failure to comply may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].

Instructions: The parent / guardian should complete this form for placement in the child’s file prior to the child’s first day of attendance. Information contained on the form shall be shared

with any person caring for the child. The department recommends that parents / guardians and center staff periodically review and update the information provided on this form.

CHILD INFORMATION

Name (Last, First, MI) Address – Home (Street, City, State, Zip Code)

Telephone Number Birthdate (mm/dd/yyyy) Date – First Day of Attendance (mm/dd/yyyy)

PARENT / GUARDIAN INFORMATION Provide information where the parent(s) / guardian(s) may be reached while the child is in care.

Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular

Name Telephone Number – Home Telephone Number – Work Telephone Number – Cellular

PHYSICIAN / MEDICAL FACILITY INFORMATION

Name – Physician Address – Medical Facility Telephone Number

SUNSCREEN / INSECT REPELLENT AUTHORIZATION If provided by the parent, the sunscreen or insect repellent shall be labeled with the child’s name. Per DCF 251.07(6)(f)2.,

authorizations shall be reviewed every 6 months and updated as necessary. Per DCF 250.07(6)(f)2.a., Authorizations shall be reviewed periodically and updated as necessary.

Yes No I authorize the center to apply sunscreen to my child.

Yes No I authorize the center to allow my child to self-apply sunscreen.

Brand Name Ingredient Strength

Yes No I authorize the center to apply repellent to my child.

Yes No I authorize the center to allow my child to self-apply repellent.

Brand Name Ingredient Strength

HEALTH HISTORY AND EMERGENCY CARE PLAN If available, attach any health care plan information from the child’s physician, therapist, etc.

1. Check any special medical condition that your child may have.

No specific medical condition

Asthma Diabetes Gastrointestinal or feeding concerns including special diet and supplements

Cerebral palsy / motor disorder Epilepsy / seizure disorder Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism

Other condition(s) requiring special care – Specify.

Milk allergy. If a child is allergic to milk, attach a statement from the medical professional indicating the acceptable alternative.

Food allergies – Specify food(s).

Non-food allergies – Specify.

DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education DCF-F (CFS-2345) (R. 03/2009)

STATE OF WISCONSIN

Page 2 of 2

2. Triggers that may cause problems – Specify.

3. Signs or symptoms to watch for – Specify.

4. Steps the child care provider should follow. If prescription or non-prescription medications are necessary, a copy of the form Authorization to Administer Medication should beattached to this form. Note: Group child care centers and day camps may use their own form.

5. Identify any child care staff to whom you have given specialized training / instructions to help treat symptoms.

a.

b.

c.

6. When to call parents regarding symptoms or failure to respond to treatment.

7. When to consider that the condition requires emergency medical care or reassessment.

8. Additional information that may be helpful to the child care provider.

SIGNATURE – Parent or Guardian Date Signed (mm/dd/yyyy)

Review dates:

DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov/ Division of Early Care and Education

DCF-F-CFS0060-E (R. 07/2013)

CHILD HEALTH REPORT – CHILD CARE CENTERS

Use of form: Use of this form is voluntary; however, completion of this form meets the requirements of DCF 202.08(4), DCF 250.07(6)(L)3.,

and DCF 251.07(6)(k)3. Failure to comply with these rules may result in issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].

Instructions: Each child under 2 years of age shall have an initial health examination not more than 6 months prior to nor later than 3

months after being admitted to the center and a follow-up health examination at least once every 6 months thereafter. Except for a school-aged child, each child 2 years of age or older shall have an initial health examination not more than one year prior to nor later than 3 months after being admitted to a center and a follow-up health examination at least once every 2 years thereafter. The parent / guardian shall give this form to the physician, physician assistant or HealthCheck provider to be completed, signed and dated. The licensee shall obtain a copy for the child’s record. Note: Children are also required to have on file at the child care center documentation of immunizations; it may be helpful if the parent / guardian were to include a copy of the child’s immunization record when submitting this form to the child care center.

PARENT OR GUARDIAN – Complete this section. Name – Child (Last, First, MI) Birthdate – Child (mm/dd/yyyy)

Address – Child (Street, City, State, Zip Code)

Name – Parent or Guardian (Last, First, MI)

Address – Parent or Guardian (Street, City, State, Zip Code)

HEALTH PROFESSIONAL – Complete this section. Instructions for feeding and care of child with special problems, including allergies – Specify (attach information as necessary).

Yes No Does the child have a milk allergy? If “Yes”, identify the recommended milk substitute.

Date of most recent blood lead test: (mm/dd/yyyy). Note: Children on Medicaid are required to be tested at

around ages 12 months and 24 months or once between the ages of 3 and 5 years if no previous test is documented. Lead testing is optional for children who are not on Medicaid.

Immunization(s) not to be administered to child due to medical reason(s) – Specify.

AUTHORIZATION

I certify that I have examined the above child on this date and that he / she is able to participate in child care activities.

Name – MD, PA or HealthCheck Provider (type or print) Address (Street, City, State, Zip Code)

SIGNATURE – MD, PA or HealthCheck Provider Date of Examination

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-04020L (Rev. 06/2017)

STATE OF WISCONSIN Wis. Stat. §§ 252.04 and 120.12 (16)

STUDENT IMMUNIZATION RECORD

INSTRUCTIONS TO PARENT: COMPLETE AND RETURN TO SCHOOL WITHIN 30 DAYS AFTER ADMISSION. State law requires all public and

private school students to present written evidence of immunization against certain diseases within 30 school days of admission. The current age/grade specific requirements are available from schools and local health departments. These requirements can be waived only if a properly signed health, religious or personal conviction waiver is filed with the school. The purpose of this form is to measure compliance with the law and will be used for that reason only. If you have questions regarding immunizations, or how to complete this form contact your child’s school or local health department.

PERSONAL DATA PLEASE PRINT

Step 1 Student’s Name

Birthdate (Mo/Day/Yr)

Gender

School

Grade

School Year

Name of Parent/Guardian/Legal Custodian

Address (Street, City, State, Zip)

Telephone Number

( )

IMMUNIZATION HISTORY

Step 2 List the MONTH, DAY, AND YEAR your child received each of the following immunizations. DO NOT USE A () OR (X) except to answer the question about chickenpox, Tdap, or Td. If you do not have an immunization record for this student at home, contact your doctor or public health department to obtain it.

TYPE OF VACCINE* FIRST DOSE

Mo/Day/Yr SECOND DOSE

Mo/Day/Yr THIRD DOSE

Mo/Day/Yr FOURTH DOSE

Mo/Day/Yr FIFTH DOSE

Mo/Day/Yr

DTaP/DTP/DT/Td (Diphtheria, Tetanus, Pertussis)

Adolescent booster (Check appropriate box)

Tdap Td

Polio

Hepatitis B

MMR (Measles, Mumps, Rubella)

Varicella (Chickenpox) Vaccine Vaccine is required only if your child has not had chickenpox disease. See below:

Has your child had Varicella (chickenpox) disease? Check the

appropriate box and provide the year if known:

YES year (Vaccine not required)

NO or Unsure (Vaccine required)

Has your child had a blood test (titer) that shows immunity (had disease or previous vaccination) to any of the following? (Check all that apply)

Varicella Measles Mumps Rubella Hepatitis B

If YES, provide laboratory report(s)

REQUIREMENTS

Step 3 Refer to the age/grade level requirements for the current school year to determine if this student meets the requirements.

COMPLIANCE DATA

Step 4 STUDENT MEETS ALL REQUIREMENTS Sign at Step 5 and return this form to school.

Or

STUDENT DOES NOT MEET ALL REQUIREMENTS Check the appropriate box below, sign at Step 5, and return this form to school. PLEASE NOTE THAT INCOMPLETLY IMMUNIZED STUDENTS MAY BE EXCLUDED FROM SCHOOL IF AN OUTBREAK OF ONE OF THESE DISEASES OCCURS.

Although my child has NOT received ALL required doses of vaccine, the FIRST DOSE(S) has/have been received. I understand that the

SECOND DOSE(S) must be received by the 90th school day after admission to school this year, and that the THIRD DOSE(S) and FOURTH DOSE(S) if required must be received by the 30th school day next year. I also understand that it is my responsibility to notify the school in writing each time my child receives a dose of required vaccine.

NOTE: Failure to stay on schedule may result in exclusion from school, court action and/or forfeiture penalty.

WAIVERS (List in Step 2 above, the date(s) of any immunizations your child has already received)

For health reasons this student should not receive the following immunizations

______________________________________________________________ ______________________________________________

SIGNATURE - Physician Date Signed

For religious reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)

DTaP/DTP/DT/Td Tdap, Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella

For personal conviction reasons, I have chosen not to vaccinate this student with the following immunizations (check all that apply)

DTaP/DTP/DT/Td Tdap Polio Hepatitis B MMR (Measles, Mumps, Rubella) Varicella

SIGNATURE

Step 5 This form is complete and accurate to the best of my knowledge. Check one: ( I do I do not ) give permission to share my child’s current

immunization records and as they are updated in the future with the Wisconsin Immunization Registry (WIR). I understand that I may revoke this consent at any time by sending written notification to the school district. Following the date of revocation, the school district will provide no new records or updates to the WIR. ___________________________________________________________________ ____________________________________________

SIGNATURE - Parent/Guardian/Legal Custodian or Adult Student Date Signed

DEPARTMENT OF HEALTH SERVICES Division of Public Health P-44021 (07/2016)

STATE OF WISCONSIN

Wis. Stat. § 252.04

STUDENT IMMUNIZATION LAW AGE/GRADE REQUIREMENTS

The following are the minimum required immunizations for each age/grade level according to the Wisconsin Student Immunization Law. Additional immunizations may be recommended for your child depending on his/her age. Please contact your doctor or local health department to determine if your child needs additional immunizations.

Grade/Age Number of Doses

Pre-K (ages 2 through 4 yrs) 4 DTaP/DTP/DT1 3 Polio 3 Hepatitis B5 1 MMR6 1 Varicella7

5K Kindergarten through Grade 5

4 DTaP/DTP/DT/Td1,2 4 Polio4 3 Hepatitis B5 2 MMR6 2 Varicella7

Grades 6 through 12 4 DTaP/DTP/DT/Td1 1 Tdap3 4 Polio4 3 Hepatitis B5 2 MMR6 2 Varicella7

1. D= diphtheria, T= tetanus, P= pertussis vaccine. DTaP/DTP/DT/Td vaccine for all students Pre-K through 12: Four doses are required.However, if a student received the 3rd dose after the 4th birthday, further doses are not required. Note: a dose four days or less before the 4thbirthday is also acceptable.

2. DTaP/DTP/DT vaccine for children entering 5K Kindergarten: Each student must have received one dose after the 4th birthday (either the 3rd,4th, or 5th dose) to be compliant. Note: a dose four days or less before the 4th birthday is also acceptable.

3. Tdap is adolescent tetanus, diphtheria and acellular pertussis vaccine. If a student received a dose of a tetanus-containing vaccine, such asTd, within five years before entering the grade in which Tdap is required, the student is compliant and a dose of Tdap vaccine is not required.

4. Polio vaccine for students entering grades 5K Kindergarten through 12: Four doses are required. However, if a student received the 3rd doseafter the 4th birthday, further doses are not required. Note: a dose four days or less before the 4th birthday is also acceptable.

5. Laboratory evidence of immunity to hepatitis B is also acceptable.6. MMR is measles, mumps, and rubella vaccine. The first dose of MMR vaccine must have been received on or after the first birthday Note: a

dose four days or less before the 1st birthday is also acceptable. Laboratory evidence of immunity to all three diseases (measles and mumpsand rubella) is also acceptable.

7. Varicella vaccine is chickenpox vaccine. A history of chickenpox disease or laboratory evidence of immunity to varicella is also acceptable.

DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education

AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS

INSTRUCTIONS FOR USE Use of form: This form is mandatory for family child care centers to comply with DCF 250.07(6)(f)1.a. Failure to comply may result in issuance of a noncompliance statement. This form is voluntary for group child care centers, day camps and certified providers; however, completion of this form meets the requirements of DCF 251.07(6)(f)1.a., DCF 252.44(6)(e)1.a. and DCF 202.08(4)(f) and 202.09(5)(c)., Wis. Admin. Codes. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: When a parent is requesting that the provider administer prescription or non-prescription medication to a child in care, this form shall be completed and signed by the parent or guardian before any medication is administered. A separate form shall be used for each medication. Place the form in child's file when medication is no longer required / authorized. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. CERTIFIED CHILD CARE CENTERS: This form is voluntary for certified providers; however, completion of Page 1 Medication Information and Authorization and Page 2 Documentation of Medication Administration – Certified Child Care Providers meets the requirements of DCF 202.08(4)(f) and 202.09(5)(c)., Wis. Admin. Codes. Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization. Record administration of the authorized medication in the spaces provided on Page 2 Documentation of Medication Administration – Certified Child Care Providers. Lines should not be skipped. LICENSED FAMILY CHILD CARE CENTERS: Page 1 Medication Information and Authorization is mandatory for family child care centers to comply with DCF 250.07(6)(f)1.a. Failure to comply may result in issuance of a noncompliance statement. Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization. Page 2 Documentation of Medication Administration – Certified Child Care Providers, is only for use by certified child care providers. It is not used by Family Child Care Centers because medication administration must be documented in the center medical log book on the day that the medication is administered. Log the dates and times medication was administered in the center medical log book. Blanket authorizations that exceed the length of time specified on the label are prohibited; no medication intended for use by a child in the care of the center may be kept at the center without a current medication administration authorization from the parent. For more information, see the document Directions for Use of Center Medication & Injury Log or Logs available from the Child Care Information Center website as part of the Appendix J Resource List. LICENSED GROUP CHILD CARE AND DAY CAMPS: Page 1 Medication Information and Authorization is voluntary for group child care centers and day camps; however, completion of this form meets the requirements of DCF 251.07(6)(f)1.a. and DCF 252.44(6)(e)1.a., Wis. Admin. Codes. Have the child’s parent or guardian complete and sign Page 1 Medication Information and Authorization. Page 2 Documentation of Medication Administration – Certified Child Care Providers, is only for use by certified child care providers. It is not used by Group Child Care Centers because medication administration must be documented in the center medical log book on the day that the medication is administered. Log the dates and times medication was administered in the center medical log book. Blanket authorizations that exceed the length of time specified on the label are prohibited; no medication intended for use by a child in the care of the center may be kept at the center without a current medication administration authorization from the parent. For more information, see the document Directions for Use of Center Medication & Injury Log or Logs available from the Child Care Information Center website as part of the Appendix J Resource List.

DCF-F-CFS0059-E (R. 08/2010) i

DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education

AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS MEDICATION INFORMATION AND AUTHORIZATION

A. FACILITY AND CHILD INFORMATION Name – Child Care Center Name – Child

Birthdate (mm/dd/yyyy)

B. MEDICATION INFORMATION: Medication shall be in the original container and labeled with the child’s name. The label shall include dosage and directions for administration.

Name – Medication Dosage Time(s) of Day to be Administered

How to be Administered

Dates – Medication Time Period From To

AM PM

AM PM

AM PM

AM PM

Yes No Does the over-the-counter (OTC) medication label indicate the child’s physician should be consulted? If “Yes” I have consulted with my child’s physician, and I am authorizing a dosage consistent with the physician’s recommendation. Name – OTC Medication Parent Initials

Additional information / special instructions / contraindications – Specify.

C. AUTHORIZATION

I hereby authorize administration of the above medication to my child by staff of the child care center listed above.

SIGNATURE – Parent or Guardian

Date Signed

DCF-F-CFS0059-E (R. 08/2010) 1

DEPARTMENT OF CHILDREN AND FAMILIES dcf.wisconsin.gov Division of Early Care and Education

AUTHORIZATION TO ADMINISTER MEDICATION – CHILD CARE CENTERS DOCUMENTATION OF MEDICATION ADMINISTRATION – CERTIFIED CHILD CARE PROVIDERS

Instructions: This section is to be completed only by certified child care providers to document the actual administration of the medication. Lines should not be skipped. Date Administered Time Administered Dosage Signature / Initials of Person Who Administered the Medication 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

DCF-F-CFS0059-E (R. 08/2010) 2