Child Care Disclosure Form 

Ohio Revised Code (ORC 2919.224-2919.227) states:
Child care providers cannot knowingly misrepresent any factor or condition that relates to the care of a child and that substantially affects the health or safety of a child in the provider’s home or facility.  Prior to accepting a child into care, all providers must disclose to the child’s caretaker information concerning a child’s death or serious injury while in their care. 
This form contains information that is accurate only at the time the form is given to you.  The information provided in this form is likely to change over time.  It is the duty of the person responsible for the care of the child to monitor the status of child care services to ensure that those services remain satisfactory.  If a question on this form is left unanswered, the child care provider makes no assertion regarding the question. 
Choosing appropriate child care for a child is a serious responsibility, and the person responsible for the care of the child id encouraged to make all appropriate inquires.  Also, in acknowledging receipt of this form, the person responsible for the care of the child acknowledges that in selecting the child care provider the person is not relying on any representations other than those provided in this form unless the child care provider has acknowledged the other representations in writing.

1. What are the names and qualifications to provide child care of:
1. The child care provider? ______________________
2. The employee who will provide child care to the applicant child? ______________________
3. The volunteer who will provide child care to the applicant child? ______________________
4. Any other employees or volunteers of the child care provider? ______________________
    

2. What is the maximum number of children to whom you provide child care at one time?  (If children are divided into groups or classes, please describe the maximum number of children in each group or class and indicate the group or class in which the applicant child will be placed): __________
    

3. Where in the home will you provide child care to the applicant child? _______________________________
    

4. Has a child died while in the care of, or receiving child care from, the child care provider?  (Yes / No) Description/explanation (attach additional sheets if necessary)
    

5. Has a child died as a result of injuries suffered while under the care of, or receiving child care from, the child day-care provider?  (Yes / No) description/explanation (attach additional sheets if necessary)
    

6. Within the preceding ten years, has a child suffered injuries while under the care of, or receiving child care from, the child care provider that led to the child being hospitalized for more than 24 hours?  (Yes / No)  Description/explanation (attach additional sheets if necessary)

Name of child care provider completing form: ___________________________________________________
Signature of child care provider completing form: ___________________________________________________
Date: _____________________

Acknowledgment:
I hereby acknowledge that I have been given a copy of the Child Care Disclosure Form and have read and understood its contents.  I further acknowledge that I am not relying on any other representations in selecting the child care provider unless the child care provider has acknowledged the other representation in writing.