NBCDC Child(ren) Records

Please fill in all blanks or write N/A
Child(ren) Name
Birthdate(s)*
Enrollment Date

MonthDayYear
Date
Updates
DATE RECORD HAS BEEN REVIEWED
Date Care Ceased

MonthDayYear
Date
Parent or Guardian's Home Address and Employment Address
Father/GUARDIAN #1 (Person Enrolling Child into Child Care Center)
FULL NAME
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)
EMPLOYER INFORMATION
Parent/Guardian #1 EMPLOYER
EMPLOYER ADDRESS
EMPLOYER CITY
EMPLOYER PHONE
EMAIL (example@example.com)
PARENT/GUARDIAN #2
FULL NAME
ADDRESS
CITY
PHONE
EMAIL (example@example.com)
EMPLOYER INFORMATION
Parent/Guardian Parent #2 Employer
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)
Person(s) to Whom the Child(ren) may be Released by the Caregiver: ALL FIELDS MUST BE FILLED OUT PER STATE REGULATIONS (If no one, please write "none")
PERSON #1
FULL NAME
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)
PERSON #2
FULL NAME
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)
Person(s) Who Will Take Responsibility for the Child(ren) in an Emergency When the Parent (or Guardian) Cannot be reached:

(ONE NAME MUST BE GIVEN)
PERSON #1
FULL NAME
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)
PERSON #2
FULL NAME
ADDRESS
CITY
PHONE NUMBER
EMAIL (example@example.com)

Consent to Contact Physician in Emergency
In the event that I cannot be reached to make arrangements, I hereby give consent to:
New Beginnings CDC Staff
to contact Doctor:
(NAME OF PHYSICIAN)
PHONE NUMBER
ADDRESS

Street Address Line 2

CITYState / Province

Postal / Zip Code
and, if necessary, take my child(ren) to the following:
Doctor(s), Clinics, or Hospital
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
MEDICATION COMPETENCY STATEMENT
I,

Parent First NameParent Last Name
Have determined that:
New Beginnings Child Development Center
is/are competent to give or apply medication to my child(ren)."
Signature of Parent/Guardian

Clear
SIGN HERE IF YOU AGREE WITH THE ABOVE STATEMENT, GIVING NBCDC STAFF PERMISSION TO ADMINISTER MEDICATION TO YOU CHILD(REN)
MonthDayYear
Date
Current health status or any health problems caregiver should know?
Medication (If any)
LIST MEDICATION(S)
List any allergies and/or intolerance to food, insect bites, or stings, or other factors that result in a medical reaction. Please give clear instructions in the event of an exposure of the factor
Special Concerns: (Glasses, Hearing Aid, Crutches):
Any activities child(ren) should NOT engage in
Company providing health and/or accident insurance coverage (Optional)
I certify that the above information is correct to the best of my knowledge.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
File Upload

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