CHILD INFORMATION
Child's Full Name: ______________________________
Date of Birth: _______________
Hair Color: __________ Eye Color: __________ ID Marks: _________________________
FAMILY INFORMATION
Mother's Name: ______________________________ Phone #: _______________
Street Address: ______________________________
City: ______________________________ State: __________ Zip: __________
Employer: _______________________________ Phone #: _______________
Street Address: _______________________________
City: _______________________________ State: __________ Zip: __________
Comments: ________________________________________________________________
Father's Name: ________________________________ Phone #: _______________
Street Address: ________________________________
City: ________________________________ State: __________ Zip: __________
Employer: ________________________________ Phone #: _______________
Street Address: ________________________________
City: ________________________________ State: __________ Zip: __________
Comments: ________________________________________________________________
Parent's Are: Married/Divorced/Separated/Widowed/Single
Parent/Guardian with Legal Custody: _______________
Siblings/ages: ________________________________________________________________
EMERGENCY INFORMATION:
Emergency Contacts (persons to be contacted in case of an emergency when parents cannot be reached)
Name: ________________________________ Phone #: _______________
Street Address: ________________________________
City: ________________________________ State: __________ Zip: __________
Relationship: ________________________________
Name: ________________________________ Phone #: _______________
Street Address: ________________________________
City: ________________________________ State: __________ Zip: __________
Relationship: ________________________________
AUTHORIZED PICK-UP PEOPLE:
Persons other than parents and emergency contacts authorized to pick-up my child from day care.
Name: __________________________ Relationship: __________ Phone #: _______________
Name: __________________________ Relationship: __________ Phone #: _______________
Name: __________________________ Relationship: __________ Phone #: _______________
CHILD'S PEDIATRICIAN/SOURCE OF HEALTH CARE:
Doctor: ______________________________ Phone #: _______________
Perfered Hospital: ______________________________________________
MEDICAL INSURANCE INFORMATION:
Subscriber's Name: _________________________________________
Insurance Company: _________________________________________
Policy #: _________________________________________
