Child's Pre-Admission Record

CHILD'S PREADMISSION RECORD

This section is to be completed by the child's parent or guardian. This form must be kept in the child's file in the Child Care Facility (home/center Child's (home/center)
Childs Name
Name child is known by
Childs birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Childs home address
Name(s) of Parent(s) / Guardian(s) (that you go by):
Home telephone number
Please enter a valid phone number.Format: (000) 000-0000.
Address of parents/guardians
Mother's Employer
Mother's Email Address
example@example.com
Employer's address
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Employer
Father's Email Address
example@example.com
Employers address
Employer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Instructions regarding how parent/guardian may be reached in an emergency
Emergency Contacts / Authorized Pickup

Parents do not need to be listed below. All columns need to be complete for each authorized pickup.

Person(s) to be contacted in an emergency if parent(s)/guardian(s) cannot be reached, full information must be provided for each contact:

Rows	Name	Relationship to Child	Address	Telephone Number
1
2
3

Name of child's doctor
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe any special needs or instructions below
Person's Child May Be Released To
How many people would you like to list?
Person #1 Full Name
Relationship to Child
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person #2 Full Name
Relationship to Child
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person #3 Full Name
Relationship to Child
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person #4 Full Name
Relationship to Child
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person #5 Full Name
Relationship to Child
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 parentguardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Permissions

Please select yes or no for each question below.
I give permission for my child to participate in activities away from the facility.
Signature of parentguardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give permission for my child to participate in transportation provided by the facility.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give permission for my child to participate in swimming/wading activities provided by the facility.
Signature of parentguardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

CHILD'S PREADMISSION RECORD

Emergency Contacts / Authorized Pickup

Person's Child May Be Released To

Permissions