________________________________________________
Child's Name__________________________________________________
Parent/Guardian name ________________________________________________
Address ______________________________________________ phone __________________
Employer ______________________________________________phone __________________
Address ________________________________________________
Child's Doctor ________________________________________ phone _____________________
Address __________________________________________________________
Health Insurance Plan__________________________________ Number_______________________
If parents cannot be contacted in an emergency, please contact:
Name________________________________relationship to child__________________________
Address__________________________________________ phone _____________________
Alternate emergency contact:
Name ________________________________ relationship to child__________________________
Address __________________________________________ phone _____________________
Alternate emergency contact:
Name ________________________________ relationship to child ___________________________
Address __________________________________________ phone _______________________
List every person, including parents, who have authority to pick up the child:
1. _________________________________________ 2. __________________________________________
3. __________________________________________ 4. ___________________________________________
Is anyone specifically denied permission to see your child?
__________________________________________________________________________________________
Does your child have any unusual eating habits or food dislikes? (explain)
__________________________________________________________________________________________
Is your child toilet trained? __________
Does your child need help in:
____________ Dressing or undressing__________washing
_____________Eating __________Toileting
Does your child usually nap? ___________ Time ___________ How long ___________
Does your child have any special needs?
Other children living at home? _________
Name _____________________________________ Age ______________
Name ______________________________________ Age ______________
Name ______________________________________ Age _______________
Name ______________________________________ Age _______________
Is there any further information that might be helpful in understanding and caring for your child?
Physician or medical facility:
Name _______________________________________ Address _____________________________________
Telephone number ______________________________________
Authorization
______ Yes ________ No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately..
_______ Yes _______ No I have had an opportunity to review the policies of this day care center and a summary of the rules for licensing day care centers.
_______ Yes _______ No I give permission for my child to participate in field trips and other activities during operating hours. _______ transported _______ walking
( A written permission slip will be sent home for each planned field trip or actvity off of day care property._
Signature parent or guardian: _________________________________________________________
Date signed: _________________________