Temporary Child Care Form

Temporary Child Care Form

Please complete this form to provide essential information for temporary child care arrangements.
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email Address*
example@example.com
Dates and Times Care is Needed*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
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?

YesNo
Please list the diagnosis details
Please explain the child's triggers
Can you provide a copy of the IEP or behavior plans?

YesNo
Parent/Guardian Authorization Signature*
Should be Empty: