CHILD'S PREADMISSION RECORD

Child's First NameChild's Last Name

Child's Date of Birth

Child's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Parents and Guardians

Parent or Guardian 1Parent or Guardian 2

Phone Numbers

Parent or Guardian 1Parent or Guardian 2

Parent or Guardian Employer

Parent or Guardian 1 EmployerParent or Guardian 2 Employer

Email

Parent or Guardian 1 EmailParent or Guardian 2 Email

Employer Address

Parent or Guardian 1Parent or Guardian 2

Employer Phone Number

Parent or Guardian 1Parent 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 NameDoctor'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.)

MonthDayYear

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.

Date

I give permission for my child to participate in: Select all that apply

Sign for Agreement for the choices selected above

This section is to be completed by the facility's staff.

Child's First Day of Attendance:Child's Withdrawal Date: