Temporary Child Care Form
Please complete this form to provide essential information for temporary child care arrangements.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Dates and Times Care is Needed
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does the child have any allergies or medical conditions? If yes, please specify.
Additional Instructions or Notes for the Caregiver
Does the child have a diagnosis?
Yes
No
Please list the diagnosis details
Please explain the child's triggers
Can you provide a copy of the IEP or behavior plans?
Yes
No
Parent/Guardian Authorization Signature
*
Submit
Submit
Should be Empty: