Pathfinder Child Information Record

State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing

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.

Name of Child*

First NameMiddle InitialLast Name

Childs Date of Birth*

Date

Address (Number and Street, Building/Apartment Number)*

Address Number and Street BuildingApartment Number

Street Address Line 2

CityState

Zip Code

Parent/Guardian 1 First and Last Name*

Parent/Guardian 1 Cell Phone*

Please enter a valid phone number.

Parent/Guardian 1 Address (If different than child's address)

Address Number and Street BuildingApartment Number

Street Address Line 2

CityState

Zip Code

Parent/Guardian 1 Employer Name*

Parent/ Guardian 1 Employer Phone Number (Write none if not applicable)*

Please enter a valid phone number.

Parent/Guardian 2 First and Last Name (Write none if this does not apply)*

Parent/Guardian 2 Legal Guardian Cell Phone (Write none if not applicable)*

Please enter a valid phone number.

Parent/Guardian 2 Address (If different than child's address)

Address Number and Street BuildingApartment Number

Street Address Line 2

CityState

Zip Code

Parent/Guardian 2 Employer Name (Write none if not applicable)*

Parent/Guardian 2 Work Phone (Write none if not applicable)*

Please enter a valid phone number.

Name of Childs Physician or Health Clinic*

Physician or Health Clinic's Phone Number*

Please enter a valid phone number.

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and Special Instructions: Please specify the type and severity of reaction that occurs. Please write "none" if there is nothing to add.*

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. (If more individuals, Please send as an email to receptionist@thepathfinderschool.org.)

Emergency Contact #1 Name*

First NameLast Name

Emergency Contact #1 Phone Number*

Please enter a valid phone number.

Emergency Contact #2 Name*

First NameLast Name

Emergency Contact #2 Phone Number*

Please enter a valid phone number.

Emergency Contact #3 Name

First NameLast Name

Emergency Contact #3 Phone Number

Please enter a valid phone number.

Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. If more individuals, please email receptionist@thepathfinderschool.org.

Child Release Contact #1

First NameLast Name

Child Release Contact #1 Phone

Please enter a valid phone number.

Child Release Contact #2

First NameLast Name

Child Release Contact #2 Phone

Please enter a valid phone number.

Child Release Contact #3

First NameLast Name

Child Release Contact #3 Phone

Please enter a valid phone number.

Child Release Contact #4

First NameLast Name

Child Release Contact #4 Phone

Please enter a valid phone number.

Initials* I give permission to The Pathfinder School*, licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while in care.

I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form. *

Today's Date*

Date

CHILD INFORMATION RECORD