Child's Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Name/Legal Guardian
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone Number
*
Please enter a valid phone number.
Business Name
Business Telephone Number
Please enter a valid phone number.
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name/Legal Guardian
*
First Name
Last Name
Home Telephone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Name
Business Telephone Number
Please enter a valid phone number.
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person(s)
Emergency Contact Person Name #1
*
First Name
Last Name
Emergency Contact Person Number #1
*
Please enter a valid phone number.
Emergency Contact Person Name #2
*
First Name
Last Name
Emergency Contact Person Number #2
*
Please enter a valid phone number.
Person(s) to whom child may be released
Person to whom child may be released : Name #1
*
First Name
Last Name
Person to whom child may be released : Address #1
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person to whom child may be released : Number #1
*
Please enter a valid phone number.
Person to whom child may be released : Name #2
First Name
Last Name
Person to whom child may be released : Address #2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person to whom child may be released : Number #2
Please enter a valid phone number.
Name of Child's Physician/Medical care provider
Full Name
*
First Name
Last Name
Telephone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Disabilities (If any)
Allergies (Including Medication Reaction)
Medical or Dietary information necessary in an emergency situation
Medication, Special conditions
Additional information on special needs of child
Health insurance coverage for child or Medical assistance benefits
Policy Number
*
Parent's Signature is required for each other item below to indicate parental consent.
Obtaining emergency medical care
Admin of minor first - aid procedures
Walks and trips
Swimming
Transportation by the facility
Wading
Periodic Review.
Signature of Parent or Guardian
*
Date
*
-
Month
-
Day
Year
Date
Signature of Parent or Guardian
*
Date
*
-
Month
-
Day
Year
Date
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