Dhr Cdc 739 Form PDF Details

Ensuring the safety, wellbeing, and proper care of children in child care facilities is paramount, and this is where the Dhr Cdc 739 form, or the Child's Preadmission Record, plays a critical role. Revised in January 2006, this document serves as a comprehensive record that must be completed by a child's parent or guardian before admission into any child care facility, be it a home or a center. It gathers essential information about the child, including their name, birthdate, home address, and the names and contact details of their parents or guardians. Beyond basic identification and contact information, it delves into specifics about the child's medical provider, emergency contact persons, and permissions for activities and emergency medical treatments. Moreover, it requires details on any special needs or instructions that the care facility staff should be aware of to ensure tailored care and safety protocols are in place. This record is also a space for parents to denote with whom the child can be released and to give consent for various activities provided by the facility, such as off-site excursions and swimming or wading activities. The form underscores the joint responsibility of the parents or guardians and the child care facility in safeguarding and promoting the welfare of children, making it an indispensable tool in child care administration.

QuestionAnswer
Form NameDhr Cdc 739 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdhr cdc 737, cdc 739, child's preadmission record dhr 739, alabama dhr cdc 739

Form Preview Example

H.Child's preadmission record

DHR-CDC-739

Revised 1/06

CHILD' S PREADMISSION RECORD

This section is to be completed by the child's parent or guardian. This form must be kept in the child's file in the

Child Care Facility (home/center).

Child’s Name:

 

Name child is known by:

 

 

 

 

 

Child’s birthdate:

 

Child’s home address:

 

 

 

 

 

Name(s) of parent(s)/guardian(s):

 

Home telephone number: (

)

 

 

 

 

Address of parent(s)/guardian(s):

 

 

 

 

 

 

 

Mother’s employer:

 

Father’s employer:

 

 

 

 

 

Employer’s address:

 

Employer’s address:

 

 

 

 

 

Employer’s telephone number: (

)

Employer’s telephone number: (

)

 

 

List telephone numbers such as beeper, cellular phone,

Instructions regarding how parent/guardian may be

etc.

 

reached in an emergency:

 

 

 

 

 

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached:

Name

Relationship to child

Address

Telephone number

Name of child’s doctor:

Address:

Telephone number:

( )

:

I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

____________________________/ _______________

Signature

Date

Page one of two-form not valid without second page

91

Effective January 22, 2001/Reprinted January 2006

Child’s Preadmission Record (continued) - page two of two - form not valid without first page

Describe any special needs or instructions below:

Person(s) the child may be released to:

Name

Relationship to child

Address

Telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________/___________

Signature of parent/guardian

Date

I give permission for my child to participate in:

(Circle yes or no and sign each line)

 

Activities away from the facility:

yes

no

Signature of parent/guardian

Date

 

 

 

 

 

 

 

 

 

 

 

 

Transportation provided by the facility:

yes

no

Signature of parent/guardian

Date

 

 

 

 

 

 

 

 

 

 

 

 

Swimming/wading activities provided by

yes

no

Signature of parent/guardian

Date

 

the facility:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________________________________________________________

This section is to be completed by the facility's staff.

Child’s first day of attendance: ___________________

Child’s withdrawal date: __________________

Additional information may be attached.

92

Effective January 22, 2001/Reprinted January 2006

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Pay close attention when filling in this form. Ensure all required fields are filled out correctly.

1. The dhr form 739 fillable pdf necessitates particular details to be typed in. Ensure the subsequent blank fields are complete:

Completing section 1 of alabama dhr cdc 739

2. Just after this array of blank fields is filled out, go to type in the applicable details in these - Address, Name of childs doctor, Telephone number, Signature, Date, cid, and Effective January Reprinted.

Filling in part 2 in alabama dhr cdc 739

3. Your next step is simple - fill in all of the form fields in Childs Preadmission Record, Name, Relationship to child, Address, and Telephone number to conclude this segment.

Relationship to child, Telephone number, and Address inside alabama dhr cdc 739

4. It's time to fill out the next portion! Here you'll have these Activities away from the facility, Transportation provided by the, Swimmingwading activities provided, yes, Signature of parentguardian, Date, yes, Signature of parentguardian, Date, yes, Signature of parentguardian, Date, This section is to be completed, Childs withdrawal date, and Additional information may be blank fields to fill out.

Filling out segment 4 of alabama dhr cdc 739

As for Activities away from the facility and yes, be certain you review things here. Both of these are certainly the most significant ones in the page.

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