| CHILDCAREFORM |
| CHILD CONTACT FORM PLEASE LIST AS MANY POSSIBLE PEOPLE THAT MIGHT COME TO PICK UP YOUR CHILD. I WILL NOT PERMIT YOUR CHILD TO LEAVE WITH ANYONE NOT ON THIS LIST. IN ADDITION TO THIS LIST, ANYONE ON THIS LIST WILL NEED ID AND AT THE TIME OF PICK-UP I WILL NEED TO CALL THE PARENT TO CONFIRM AND GET A BRIEF DESCRIPTION. THIS PERSON WILL ALSO HAVE TO KNOW THE KIDCODE YOU HAVE CHOSEN. YOUR CHILD SHOULD NOT KNOW THE KIDCODE (THEY TEND TO TELL ALL): ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ PERSONS NOT AUTHORIZED TO TAKE YOUR CHILD: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ KIDCODE:_______________________________________________________________________________ PLEASE LIST YOUR SUBSTITUTE PROVIDER. THESE WILL ONLY BE CALLED IF YOUR CHILD HAS BECOME TOO ILL TO STAY OR IF I SHOULD BECOME ILL. HOPEFULLY WE WILL NEVER HAVE TO USE THIS VENUE(PLEASE HAVE THESE PEOPLE WITHIN A 20 MILE RADIUS): NAME ADDRESS PHONE# _______________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ PARENT/GUARDIAN SIGNATURES AND PROVIDER: DATE MOTHER_______________________________________________________________________________ FATHER:________________________________________________________________________________ GUARDIAN 1____________________________________________________________________________ GUARDIAN 2____________________________________________________________________________ PROVIDER______________________________________________________________________________ |
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| THIS FORM WOULD WITH NEW APPLICANT/CHILD WELCOME FOLDER. I ALSO WOULD SCAN AND COPY FINISHED FORM. THE ORGININAL FOR CHILDS FILE IN MY FILES AND THE COPY FOR PARENTS/GUARDIANS TO KEEP IN THEIR WELCOME FOLDER. |
| Form Page |