CHILD'S PREADMISSION RECORD
Child's First Name
Child's Last Name
Child's Date of Birth
Child's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Parents and Guardians
Parent or Guardian 1
Parent or Guardian 2
Phone Numbers
Parent or Guardian 1
Parent or Guardian 2
Parent or Guardian Employer
Parent or Guardian 1 Employer
Parent or Guardian 2 Employer
Email
Parent or Guardian 1 Email
Parent or Guardian 2 Email
Employer Address
Parent or Guardian 1
Parent or Guardian 2
Employer Phone Number
Parent or Guardian 1
Parent or Guardian 2
Person(s) to be contacted in case of an emergency if parent(s) or guardian(s) cannot be reached. [Name-Relationship-Address-Telephone Number]
Child's Doctor
Doctor's Name
Doctor's Number
Emergency Authorization I give permission to 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.)
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Month
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Day
Year
Date Picker Icon
Describe any special needs or instructions below:
Person(s)child can be released to: [Name-Relationship-Address-Telephone Number]
I understand that the Department of Human Resource does not inspect activities away from the child care facility (home or center). The license of the child care facility assumes full responsibility for such activities.
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Month
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Day
Year
Date
I give permission for my child to participate in: Select all that apply
Activities away from the facility:
Transportation provided by the facility:
Swimming/wading activities provided by the facility:
Sign for Agreement for the choices selected above
Submit
Submit
This section is to be completed by the facility's staff.
Child's First Day of Attendance:
Child's Withdrawal Date:
This child meets the definition of homelessness according to the McKinney-Vento Homeless Assistance Act.
Should be Empty: