CHILD' S PREADMISSION RECORD

CHILD' S PREADMISSION RECORD

DHR-CDC-739
Child's Full Name
Child's Nickname
Child's Birthdate

MonthDayYear
Date
Child's home address
Name(s) of parent(s)/guardian(s)
Home Telephone Number
Address of parent(s)/guardian(s)
Mother's Employer
Father's Employer
Mother's Email Address
example@example.com
Father's Email Address
example@example.com
Employer's Address (Mother)
Employer's Address (Father)
Employer's Telephone Number (Mother)
Employer's Telephone Number (Father)
List other telephone numbers such as pager, cellular phone, etc.
Instructions regarding how parent/guardian may be reached in an emergency
List a person to be contacted in an emergency if the parent(s)/guardian(s) cannot be reached. Note: two additional emergency contacts may be added at a later date.
Emergency Contact Name
Emergency Contact Relationship to Child
Emergency Contact Address
Emergency Contact Telephone Number
Name of Child's Doctor
Address of Child's Doctor
Telephone Number of Child's Doctor
Emergency Authorization: I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)
Signature of Parent/Guardian

Powered by Jotform SignClear
Date

MonthDayYear
Date
Describe any special needs or instructions below
Aside from parent(s)/guardian(s), list a person the child may be released to. Note: up to four additional persons the child may be released to may be added at a later date.
Authorized for Pick-Up Name
Authorized for Pick-Up Relationship to Child
Authorized for Pick-Up Home Address
Authorized for Pick-Up Telephone Number
I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licensee of the child care facility assumes full responsibility for such activities.
Signature of Parent/Guardian

Powered by Jotform SignClear
Date

MonthDayYear
Date
I give my child permission to participate in activities away from the facility:

YesNo
Signature of Parent/Guardian

Powered by Jotform SignClear
Date

MonthDayYear
Date
I give my child permission to participate in transportation provided by the facility:

YesNo
Signature of Parent/Guardian

Powered by Jotform SignClear
Date

MonthDayYear
Date
I give my child permission to participate in swimming/wading activities provided by the facility:

YesNo
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Form not valid without signature of child's parent/guardian in each space indicated above.
Should be Empty: