Phone: (216) 862-0672
Fax: (216) 862-0692
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Child's Name(Required)
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PRIMARY GUARDIAN:

Name(Required)
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Address(Required)
Marital Status:

OTHER GUARDIAN:

Name
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Address

Authorized Pick-Up

The following person(s) are authorized to pick up my child in the event I am unable to do so.
Name
Relationship to Child
Phone Number
 
The following person(s) should know my schedule at all times, in the event of an emergency and I can not be reached, please contact any of the following.)
Name
Relationship to Child
Phone Number
 
This field is for validation purposes and should be left unchanged.

Ohio Department of Job and Family Services (ODJFS) FORMS

ROUTINE TRIP PERMISSION FOR CHILD CARE
BASIC INFANT INFORMATION FOR CHILD CARE
CHILD MEDICAL STATEMENT FOR CHILD CARE
CHILD MEDICALPHYSICAL CARE PLAN FOR CHILD CARE