Yearly Child File Update
This form is to be updated yearly for your child's file, emergency information, and transportation permission.
Child's First and Last Name
*
Child's Date of Birth
*
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Month
-
Day
Year
Date Picker Icon
Child's Age
*
Parent/Guardian 1 Full Name
*
Parent/Guardian 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Child
*
Please Select
Mother
Father
Guardian
Address (street, city, state, zip code)
*
Email
*
Parent/Guardian 2 Full Name
*
Parent/Guardian 2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Child
*
Please Select
Mother
Father
Guardian
Address (street, city, state, zip code)
*
Email
*
Back
Next
Emergency Contact 1 Full Name & Relationship to Child
*
Contact 1 Phone Number
*
Contact 1 Address (street, city, state, zip code)
*
Emergency Contact 2 Full Name & Relationship to Child
*
Contact 2 Phone Number
*
Contact 2 Address (street, city, state, zip code)
*
Is there anyone specific who should NEVER pickup your child?
*
Yes
No
Name, Relation to Child, and Reason
*
Back
Next
Name of Physician, Address, and Phone Number
*
Preferred Hospital (name, address, and phone)
*
Cook Children's Medical Center, 801 7th Ave, Ft Worth, Tx, 682-885-4000
Texas Health and Huguley, 11801 S. Fwy, Burleson, Tx, 817-293-9110
Baylor Medical Center, 1400 8th Ave, Ft Worth, Tx, 817-926-2544
Second Choice Hospital (name, address, and phone)
*
Cook Children's Medical Center, 801 7th Ave, Ft Worth, Tx, 682-885-4000
Texas Health and Huguley, 11801 S. Fwy, Burleson, Tx, 817-293-9110
Baylor Medical Center, 1400 8th Ave, Ft Worth, Tx, 817-926-2544
I give consent to the facility to secure any and all necessary emergency medical care for my child.
*
Yes
I give consent for the facility to transport my child to/from school, for emergency purposes, and to field trips if necessary.
*
Yes
No
Does your child have any special needs or accommodations?
*
Yes
No
Please share details of the special needs or accommodations your child requires (type NONE if your child doesn't have any).
*
Is your child on any continuous, long term use medications?
*
Yes
No
List any and all continuous use medications and dosage (type NONE if your child doesn't have any).
*
List any allergies (type NONE if your child doesn't have any)
*
By typing my name below, I acknowledge that all information is true, accurate, and give consent for RCLC to use.
*
Today's Date
*
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Month
-
Day
Year
Date Picker Icon
Submit
Submit
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