Name of child:_________________________________________________________________
Last
First
Middle
Birthdate___________________Age_______Sex___________
Address______________________________________________________________________
Street
City Zip
Parent/Guardian Information
1. Parent's Name ________________________________________SS#__________________
Home Phone___________________________ Work Phone____________________________
Pager or Cellular Phone________________________
Location of parent while child is in care_____________________________________(be specific)
2. Parent's Name ________________________________________SS#___________________
Home Phone___________________________ Work Phone_____________________________
Pager or Cellular Phone________________________
Location of parent while child is in care_____________________________________(be specific)
Parent/Guardian with legal custody_______________________________________
Custody Restrictions Yes____No____If so, Release Only to_________________
Emergency Contacts
1. Name________________________________2.
Name________________________________
Home/Work Phone__________________Home/Work
Phone____________________
Relationship to child__________________Relationship
to child__________________
3. Name________________________________4.
Name________________________________
Home/Work Phone__________________Home/Work
Phone____________________
Relationship to child_________________Relationship
to child___________________
Person (s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
1. Name__________________Comment___________________________________________
2. Name__________________Comment___________________________________________
Emergency Information
Child’s Physician_____________________________Physician's Phone
Preferred Hospital____________________________
Insurance Company___________________________Policy #____________________
Medicine allergic to_____________________________________________________
Food Allergies_________________________________________________________
Any other Allergies______________________________________________________
Any special health conditions_______________________________________________
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