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
Date
Address*

Street Address

Street Address Line 2

CityState / Province

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

Parents do not need to be listed below.

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

	Name	Relationship to Child	Address	Telephone Number
1
2
3

Name of child's doctor*
Address*
Phone Number*
Please enter a valid phone number.
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*

Clear
Date*

MonthDayYear
Date
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.
Person #2 Full Name*
Relationship to Child*
Address*
Phone Number*
Please enter a valid phone number.
Person #3 Full Name*
Relationship to Child*
Address*
Phone Number*
Please enter a valid phone number.
Person #4 Full Name*
Relationship to Child*
Address*
Phone Number*
Please enter a valid phone number.
Person #5 Full Name*
Relationship to Child*
Address*
Phone Number*
Please enter a valid phone 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 parentguardian*

Clear
Date*

MonthDayYear
Date
Permissions

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

YesNo
Signature of parentguardian*

Clear
Date*

MonthDayYear
Date
I give permission for my child to participate in transportation provided by the facility.*

YesNo
Signature*

Clear
Date*

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

YesNo
Signature of parentguardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CHILD'S PREADMISSION RECORD

Emergency Contacts / Authorized Pickup

Person's Child May Be Released To

Permissions