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NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.

CACFP Enrollment:Yes:___No:___. MARYLAND STATE DEPARTMENT OF EDUCATION Office of child Care Meals your child will receive while in care: BK___ LN___SU___ AM Snk___ PM Snk___ Evng Snk___. emergency FORM. INSTRUCTIONS TO PARENTS: (1) Complete all items on this side of the form. Sign and date where indicated. (2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child 's health practitioner review that information. NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY. child 's Name _____ Birth Date _____. Last First Enrollment Date _____ Hours & Days of Expected Attendance _____. child 's Home Address _____. Street/Apt. # City State Zip Code Parent/Guardian Name(s) Relationship Phone Number(s). Place of Employment: C: H: _____. W: Place of Employment: C: H: _____. W: Name of Person Authorized to Pick up child (daily) _____. Last First Relationship to child Address _____.

Meals your child will receive while in care: EMERGENCY FORM . B. K___ LN___SU___ AM Snk___ PM Snk___ Evng Snk___ INSTRUCTIONS TO PARENTS: (1) Complete all items on this side of the form. Sign and date where indicated. (2) If your child has a medical condition which might require emergency medical care, complete the back side of the form.

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earlychildhood.marylandpublicschools.org

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