DEPARTMENT OF CHILDREN AND FAMILIES
Division of Early Care and Education
INTAKE FOR CHILD UNDER 2 YEARS – CHILD CARE CENTERS
Use of form: This form is mandatory for family child care centers to comply with DCF 250.09(1)(c)1. and for certified providers to comply with 202.08(12)(g). Failure to comply may result in issuance of a noncompliance statement. This form is voluntary for group child care centers; however, it meets the requirements of DCF 251.09(1)(am). This form collects information about children under age 2 in order to aid child care workers in individualizing the program of care for the child in a family or group child care center. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: This form is to be completed by a parent and must be on file at the center prior to a child's first day of attendance. Regular updates can be noted. This form should be kept in the room where care is provided. If additional space is needed, attach a separate sheet
Note: Health conditions that may affect the care of the child must be recorded on the department’s form, Health History and Emergency Care Plan. The form should be shared with any person who provides care for the child.
Note: Children under age 1 year must be placed to sleep on their back unless a written statement from the child's physician is attached.
PHYSICAL AND SOCIAL DEVELOPMENT