These are from that http://supportingproviders.com/childcareforms3.htm

Add the runny nose thing to it and delete what you don't want from it.


A. HEALTH REQUIREMENTS. All children entering my childcare home must be up to date on all shots, unless there is a medical reason (documentation is required). All children also must have had a well child check within six months before enrolling into my childcare.
If a child is ill in any way, I will not, under any circumstances, be able to keep them. This rule is enforced not only for the protection myself, but my children as well. It is my policy to notify parents immediately when a child becomes ill and to make arrangements for the child to be picked up. I will need for the child to be picked up within one hour of my phone call.
In the event of head lice, children must be treated and nit free BEFORE returning. If a case is found in my home, a notice will be given to all parents and all heads in my home will be checked.
B. SICK/EXCLUSION POLICY. I have sought the advice of fellow childcare providers, and have come up with the following sick policy. For the health of not only my family, but also other children in my care and their families, this policy will be strictly enforced.
If a child is ill, you will need to call me by 9:00 p.m. the night before or a minimum of one hour before your contracted arrival time. Should your child become ill during his/her time in my home, you will be notified and I will determine the best way to handle the situation, which may include your child being sent home. It is in everyone's best interest that a sick child stays home. If a child has any of the symptoms listed below, they will not be permitted to attend care until 24 hours AFTER the last incidence of fever, vomiting, severe diarrhea, or until 24 full hours after medical treatment has begun as prescribed by a physician. The symptoms include:

Fever of 100 or higher
Skin rash other than diaper rash or prickly heat - child will not be allowed to come for care until a medical exam (written documentation from physician required) has indicated it is not a communicable disease.
Diarrhea - increased number and water content of stools that cannot be contained within the diaper or underwear.
Vomiting two or more times in the same day
Any parasitic infestation (lice, scabies, etc.)
Pink eye
Chicken pox - until all blisters have dried and formed scabs, usually about 6 days after the onset of the rash.
Any other communicable disease (tuberculosis, etc.)
! NOTE: A good rule of thumb to follow is if you have to give your child any medication to relieve any of the above-mentioned symptoms before you bring them, PLEASE KEEP THEM HOME!
Further, there are times when a child is not that ill, but is uncomfortable and really needs the comfort of home. For example, until 24 hours after the first dose of antibiotic to treat ear infection; or when irritability strong cough, and a thick nasal discharge are present during the tail end of an upper respiratory infection. At those times, I will strongly urge you to keep your child at home, and may insist on it. I ask that when deciding if your child should come, please give consideration to the health of the other children, my family, and me. My pediatrician tells me that the first two days of illness are generally the most contagious time. Although winter runny noses are somewhat unavoidable, please use your best judgment, and call me if you are unsure. If you repeatedly attempt to bring an obviously ill child, this may be grounds for termination of childcare services.

Children suspected of having a communicable disease will not be able to come into my home. In the event a communicable disease develops during the day, the child’s parents will be contacted immediately for the child to be picked up. Children must leave my home within one hour of my phone call.
When your child is sent home from care for any one of the Following Reasons listed Below, you will receive a doctor's referral. This form must be completed, signed by the physician and stamped with the physician's license number before your child may return to care. A note on a physician's prescription letterhead is also acceptable.
Communicable Diseases:
1) Chicken Pox
2) Pink Eye
3) Any parasitic infestation (lice, scabies, etc.)
Although I am trained in infant and child CPR, basic first aid, and recognition of communicable childhood diseases, I do not pretend to be a doctor, and will not under any circumstances provide any medications, including vitamins unless a “Permission to Administer Medication” form is filled out. You must provide any and all medications for your child. I will not send a child home with a common cold, unless accompanied by a fever or other severe symptoms. However, many times when young children are ill, they may not exhibit “classic” signs of the illness (fever, vomiting, etc.) but will be excessively fussy and/or require constant cuddling and attention.
While I believe in providing as much cuddling as desired, if a child is ill and requires my undivided attention this distracts from my ability to provide quality care to all the children in the group. Therefore, if your child reaches a point when he/she requires constant attention, will not play, cries continuously, whines and wants to be held constantly, etc., then your child will need to stay home.
You should expect that any time a new child is introduced to the group, colds and other minor illnesses are likely to occur until everyone’s immune systems have adjusted to the new exposures. Also, advise me whenever a member of your family has an illness so that I can be alert to the possibility of symptoms developing in the child or group.
Children may return to care only at such time as they will not longer endanger the health of other children. They must be able to participate in daily activities, and the following conditions must have been met.
Absence of fever for 24 hours
Nausea, vomiting or diarrhea has subsided for 24 hours
Children must have been on antibiotics for a period of 24 hours
Physician has approved readmission into care
Chicken pox lesions are completely crusted over
Scabies are under treatment
Lice are under treatment, and no nits are present on hair
Pinworm treatment has occurred 24 hours before readmission
Lesions from impetigo are no longer weeping
Conjunctivitis has diminished and been treated to the point that the eyes are no longer discharging
The child has completed the contagious stage of the illness.
Please note that no child will be readmitted after a communicable disease without a statement from a medical facility or physician.
C. MEDICATIONS. If your child is taking medication, please be sure to sign a release to administer medication form. I CANNOT administer medication to ANY child without this release being signed. All medication must remain in the original container and be properly labeled with the child’s full name, date prescription was filled, medication expiration date, and legible instructions for administration. Please do not leave the medication in the diaper bag - hand deliver to me.
For non-prescription medication, the following can be given with permission from the parents, only at the dose & for the duration & method of administration specified on the manufacturer's label for the age and/or weight of the child needing the medication.
Antihistamines
Tylenol
Decongestants
Anti-itching ointments/lotions
Diaper ointments/lotions
Non-narcotic cough suppressants
Non-prescription oral medications may not be administered for more than five consecutive days. All non-prescription topical ointments, creams, or lotions may not be administered for more than seven consecutive days when used for skin irritations.
I am required to have syrup of ipecac in the first-aid kit that may be administered only when following verbal instructions of the poison control center or a physician. All administrations of medications will be documented on an Incident Report, and placed in the child’s file.

Parents Signature:_________________________________________________ Date:____________________

Parents Signature:_________________________________________________ Date:____________________

Providers Signature:_______________________________________________ Date:____________________

OR

Illness Policy
PARENTS AGREE TO KEEP THEIR CHILD/CHILDREN AT HOME OR SEEK ALTERNATE CARE ARRANGEMENTS FOR THE FOLLOWING CONDITIONS:
Pain - any complaints of unexplained or undiagnosed pain
Fever (100°F/38.3°C or higher)
Sore throat or trouble swallowing
Headache or stiff neck
Unexplained diarrhea or loose stool combined with nausea, vomiting or abdominal cramps. The child will be kept at home until all symptoms have stopped.
Nausea or vomiting
Sever itching of body and scalp
Known or suspected communicable diseases.

IT IS REQUIRED TO KEEP (OR TAKE) A CHILD HOME WHEN THE CHILD:
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Is suffering from one or more of the above symptoms
Is not well enough to take part in the activities at the daycare

ULTIMATELY THE CARE OF THE CHILD IS THE PARENT'S RESPONSIBILITY

Parents will inform the daycare within 24 hours of a diagnosis of a serious illness or contagious disease of a communicable nature in the family.* This is to protect my family and the other families who attend the daycare.* Failure to do so is grounds for immediate termination of care.
Parents agree that a child will be symptom free, without the aid of symptom reducing medications such as Tylenol, for a full 24 hours prior to returning to daycare.* We reserve the right to ask for a note from your family doctor, depending on the illness/disease.
MEDICATIONS:
Prescription medications will only be given to a child in care with the following conditions:
*
Parent gives written permission to the caregiver, with full instructions as to dosage, and times to administer medication. (forms are available from the daycare for this purpose)
All prescribed medications must have the child's name on the prescription bottle.
Non-prescription medications will be administered as per recommended dosages on medicine bottle.

CARE OF A SICK CHILD AND NOTIFICATION OF PARENTS
When a child becomes ill, I will make the child comfortable in a quiet place where he/she can rest and will be closely supervised.
Parents will be notified immediately and agree to begin to making alternate work arrangements or arrangements for alternate care. If your child is seriously ill, you or an alternate must come for the child IMMEDIATELY.* If I cannot reach a parent, I will call an emergency contact listed on the registration form or the child's doctor may be contacted depending on the seriousness of the illness.
*

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