State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing Bureau
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply. "unknown" or "none" is the required response. A blank field, a line through a field or "N/A" are not acceptable responses.
Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)
Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released (If more individuals, attach additional sheets.)
Parent/Legal Guardian Initials:
I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form.
*** Please see Amanda Faiola to add a signature.
LARA is an equal opportunity employer/program.
PENALTY: Rule Violation Citation