2025/2026 CHILD INFORMATION RECORD

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.

Name of Child (Last, First, Middle Initial)*

Child's Date of Birth*

Date

Address*

Address (Number and Street, Building/Apartment Number)

Street Address Line 2

CityState

Zip Code

Parent/Legal Guardian's Name*

First and Last name

Primary Phone Number, enter as 123-456-7890 *

2nd Phone number (if applicable), enter as 123-456-7890*

If none please add "none"

Home Address *

If same as student please state "same"

City*

State*

Zip Code*

Email Address (optional)

If none please add "none"

Employer Name*

If none please add "none"

Work Phone, enter as 123-456-7890 *

If none please add "none"

2nd Parent/Legal Guardian's Name (Optional)*

If none please add "none"

Primary Phone Number, enter as 123-456-7890 *

2nd Phone number (if applicable), enter as 123-456-7890*

If none please add "none"

Home Address (if not child's address)*

If same as student please mark "same"

City*

State*

Zip Code*

Email Address (optional)

If none please add "none"

Employer Name*

If none please add "none"

Work Phone, enter as 123-456-7890 *

Name of Child's Physician or Health Clinic*

If none please add "none"

Physician's or Health Clinic's Phone Number, enter as 123-456-7890*

If none please add "none"

Hospital Preferred for Emergency Treatment (optional)*

Please state a hospital or any

Allergies, Special Needs and/or Special Instructions? YES

Please place X if there are allergies, special needs and/or special instructions.

If yes, explain

Allergies, Special Needs and/or Special Instructions? NO

Please place X if there are NO allergies, special needs and/or special instructions.

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.)

1.