Written Care Plan

Complete the portions that are helpful for your child and your child care provider. This plan can be used for any child or any time a place is needed to share information about caring for a child. It is not necessary to complete all sections of the form, please use the sections that are applicable and helpful for your child and child care provider.

Completed By

Parent/Guardian Name

About my Child

Child's Name (First,Last)

Birthdate

Month

Day

Year

Age

My family wants you to know

My preferences include

Health Information: (please include information about previous serious illness or injury, or any ongoing health issues)

Medication

Medication Authorization form completed

No medication is required

Recommendations

Diet or Feeding

Activity

Toileting

Outdoor Play

Field Trips

Transportation

Adaptive or accessibility tools and equipment

Situations and Experiences

Things that work for my child

Things that may not work for my child

Things that definitely do not work for my child

When my child is feeling seen heard, and valued, they:

When my child is feels out of place, or upset, they may show this by

When my child is upset you can help them by

Helpful strategies used at home

Emergency Response Plans

Call Parents/Guardians if the following

Call 911 (Emergency Medical Services) if the following:

Take these measures while waiting for family members or medical help to arrive:

Special factors to consider in a facility emergency; like a fire or power outage

Team Members/Support

(Name, Program and Contact Information, is applicable)

Guardian(s)

Primary Child Care Caregiver(s)

Public/Private School Teacher

Health Care Provider (MD, NP)

If applicable, add other members of your child’s support team (which may include persons like Occupational therapist (OT), Physical Therapist (PT), Speech/Language Therapist, Transportation, Social Worker, a Specialist, or other family members)

Individualized Services

Parent permission is granted for these services to happen at the child care facility: (include type of service, how often, the name of the agency providing the service, and end date, if applicable)

Action Plan

(if relevant, specify any follow-up needed here)

Action

Who

When

Action

Who

When

Notes

Parent/Guardian Signature

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Date

Applicable Oregon Administrative Rules: Registered Family Child 414-210-1050; Certified Family 414-360-1050; Certified Centers 414-305-1050; Certified School-age Centers: 414-310-0580 and Outdoor Nature Based Programs 414-320-1050.

You are entitled to language assistance services and other accommodation at no cost. If you need help in your language or other accommodation, please contact the DELC at 503-947-1400