Enrollment Forms

Ohio Department of Children and Youth

CHILD ENROLLMENT FORM FOR EARLY CARE AND EDUCATION PROGRAMS

Parents: Complete this form or an electronic version in its entirety prior to the child’s first day of attendance, review annually, and update as needed. The program may supplement or substitute this document with their own content equivalent form and request additional information from the parent/guardian.

Child’s Name

Date of Birth

First Day at Program

Address

City

State

Zip Code

Parent #1 Name

Parent #1 Phone Number

Parent #1 Address Same as Child’s address (Parent #1)

City (Parent #1)

State (Parent #1)

Zip Code (Parent #1)

Parent #1 Email Address (if applicable)

Parent #1 Cell Phone (if applicable)

Parent #1 Work/School Name (if applicable)

Parent #1 Work/School Phone Number (if applicable)

Check here if Not Applicable (Parent #2)

Parent #2 Name

Parent #2 Phone Number

Parent #2 Address Same as Child’s address (Parent #2)

City (Parent #2)

State (Parent #2)

Zip Code (Parent #2)

Parent #2 Email Address (if applicable)

Parent #2 Cell Phone (if applicable)

Parent #2 Work/School Name (if applicable)

Parent #2 Work/School Phone Number (if applicable)

Emergency contacts
Primary Emergency Contact #1	Optional Emergency Contact #2
Primary Emergency Contact #1 Name (cannot be parent/guardian)	Check here if Not Applicable (Optional Emergency Contact #2) Optional Emergency Contact #2 Name (cannot be parent/guardian)
Primary Emergency Contact #1 Phone Number	Optional Emergency Contact #2 Phone Number
Primary Emergency Contact #1 Other number or email address for emergency contact (if applicable)	Optional Emergency Contact #2 Other number or email address for emergency contact (if applicable)
My child may be released to this emergency contact Yes No	Optional My child may be released to this emergency contact Yes No

Does your child have a chronic health condition or diagnosis that requires the program to: observe or monitor symptoms, administer medication, serve medical foods, perform medical procedures, avoid specific foods/environmental conditions/activities, or allow a school age child to carry and administer their own medication? Yes (complete or provide a Health Care Plan, documentation from a licensed physician, or an electronic equivalent) No

DCY 01234 (Rev. 7/2026)Page 1 of 2

Child’s Name (page 2)

Date of Birth (page 2)

Information on my child's development: (personal, behavior, patterns, habits, and individual needs, etc.)N/A (development information)

The following accommodation(s) may be helpful to most effectively meet my child’s needs while at the program:N/A (accommodations)

My child will receive specialized/individual services at the program: Yes No

Name of service provider(s) and frequencyN/A (service provider)

Emergency Transportation Authorization

Emergency Transportation Authorization The program has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported. The program does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. I wish for the following action to be taken:

I wish for the following action to be taken

SIGNATURE

This form should be reviewed 12 months from the date the parent acknowledges accuracy and receipt of policies and procedures.

Parent Acknowledgement of Accuracy and Receipt of Policies and Procedures

By signing this form, I attest that the information is accurate and that I have reviewed and received a copy of the program’s policies and procedures (parent handbook).

Parent Signature

Date (Parent Signature)

Program Acknowledgement of Completion

By signing this form, I attest that I have reviewed for completeness and that this form has been signed by the parent/guardian. This form is to be completed prior to the child receiving care.

Program Administrator/Designee Signature

Date

Annual review
Parent/Guardian Initials	Date of Review	Administrator/Designee Initials	Date of Review
Review 1	Review 1 parent/guardian date of review
Review 2	Review 2 parent/guardian date of review
Review 3	Review 3 parent/guardian date of review

DCY 01234 (Rev. 7/2026)Page 2 of 2

Redeemer Lutheran
School & Childcare

Parent & Custody INFORMATION

Please complete this form so we have accurate information regarding your child's legal guardianship and emergency contacts.

PARENT / GUARDIAN CONTACT INFORMATION

Parent / guardian contact information
MOTHER	FATHER	STEP MOTHER (if applicable)	STEP FATHER (if applicable)
Mother Name:Mother Phone:	Father Name:Father Phone:	Step Mother Name:Step Mother Phone:	Step Father Name:Step Father Phone:

CHILD'S PRIMARY RESIDENCE

Name:

Address:

Address line 2

Phone:

LEGAL CUSTODY

VISITATION / CUSODY ARRANGEMENTS

Are there any custody restrictions or visitation arrangements the school should be aware of?

Court documents attached.

SIGNATURE

Parent / Guardian Signature:Date:

Printed Name:

Partnering together to nurture, teach and share Christ's love.

Thank you!

Child Pick-Up Permission Authorization

for Redeemer Lutheran School
Lancaster, Ohio

CHILD'S NAME:

DOB:

THE FOLLOWING PERSON/PERSONS HAVE MY PERMISSION TO PICK-UP MY CHILD

Person 1

NAME

ADDRESS

PHONE

RELATIONSHIP TO CHILD

ANY DAY/ SPECIAL DAYS

Person 2

NAME

ADDRESS

PHONE

RELATIONSHIP TO CHILD

ANY DAY/ SPECIAL DAYS

Person 3

NAME

ADDRESS

PHONE

RELATIONSHIP TO CHILD

ANY DAY/ SPECIAL DAYS

Person 4

NAME

ADDRESS

PHONE

RELATIONSHIP TO CHILD

ANY DAY/ SPECIAL DAYS

SIGNATURE OF PARENT/ GUARDIAN

DATE

Child Medical/Health Condition Plan Form

for Redeemer Lutheran School
Lancaster, Ohio

ATTACH A COPY OF THE CHILD'S IMMUNIZATION RECORD INCLUDING DATES (MM/DD/YYYY FORMAT) OF DOSES OF ALL IMMUNIZATIONS.

For each child, the immunization record should include:

Child’s full name
Child’s date of birth
Dates (month/day/year) of immunizations received
the record should be on file within 30 days of the child’s first day of attendance.
It must be updated no more than every 13 months while the child remains enrolled.

IMMUNIZATION (Complete ONLY ONE SECTION below)

Section 5104.014 of the Ohio Revised Code requires immunizations against the following diseases:

Chicken Pox.
Diphtheria, Tetanus, Pertussis (DTaP/Tdap).
Haemophilus influenzae type b.
Hepatitis A.
Hepatitis B.
Influenza (if seasonal vaccine is available).
Measles, Mumps, Rubella (MMR).
Pneumococcal disease.
Poliomyelitis.
Rotavirus.

Section A :

The above named child has been immunized against the diseases listed above.

If an immunization is medically contraindicated or not medically appropriate for the child's age, note any exceptions by listing the specific immunization(s):

Signature of Parent:

Date: (Section A)

Section B :

I have declined to have my child immunized for reasons of conscience, including religious convictions against all of the diseases listed above or against the following disease(s):

Disease(s) declined for reasons of conscience

Signature of Parent:

Date: (Section B)

DCY 01236 (Rev. 7/2026)