IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE
To Be Completed by Parent or Authorized Representative
CHILD'S NAME
*
Last
First
SEX
*
M/F/Other
BIRTH DATE
*
-
Month
-
Day
Year
Date
TELEPHONE#
*
Please enter a valid phone number.
Format: (000) 000-0000.
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT/AUTHORIZED REPRESENTATIVE NAME
*
Last
First
HOME ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOME/CELL PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
PERSON RESPONSIBLE FOR CHILD
*
Last Name
First Name
WORK/CELL PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
NAME
*
First Name
Last Name
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TELEPHONE
*
Format: (000) 000-0000.
RELATIONSHIP
*
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN
*
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
MEDICAL PLAN AND NUMBER
TELEPHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
DENTIST
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TELEPHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
*
CALL EMERGENCY HOSPITAL
OTHER EXPLAIN
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE
NAME
*
RELATIONSHIP
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
TIME CHILD WILL BE PICKED UP
Hour Minutes
AM
PM
AM/PM Option
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE
*
DATE
*
-
Month
-
Day
Year
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION
/
Month
/
Day
Year
Date
LAST DATE OF ENROLLMENT
/
Month
/
Day
Year
Date
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