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  • Publicado : 29 de octubre de 2010
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DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education


Use of form: This form isvoluntary. However, this completed form, when on file in the child's record, meets the requirements of DCF 250.04(6)(a)3. and DCF 251.04(6)(a)5. and 251.095(4)(a)2. Personal information you provide may be usedfor secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. Instructions: Complete this form for placement in the child's file when the child will arrive at the center from school, homeor other activities, or depart from the center to go to school, home or other activities, and the child will not be accompanied by a parent or other previously authorized person or transported by thecenter. This form should be updated as information changes. Periodic review with the parent / guardian is recommended to ensure safety. If the center transports the child, the department’s form“Transportation Permission – Child Care Centers” may be used to obtain parental authorization.

My child (Child’s name) will arrive at (Name of center) from (School, home or otheractivity) by way of (Walking, bicycle, bus, car pool, etc. Be as specific as possible.) at (Time of arrival) on Sunday Monday Tuesday with OR Wednesday Thursday (Days of the week) Friday Saturday A.M. ORP.M.

My child will arrive from this destination

without center supervision.

My child (Child’s name) will leave (Name of center) by way of (Walking, bicycle, bus, carpool, etc. Be as specific as possible.) to go to (School, home or other activity) at (Time of departure) on Sunday Monday Tuesday Wednesday Thursday (Days of the week) Friday Saturday A.M. OR P.M.

Mychild will travel to this destination

with OR

without center supervision.


I understand that I am responsible for notifying the center of any changes in this...
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