Child's Record

Others in Household:

Name Age Relationship

List additional persons who may be called in the event of an emergency, and who are authorized to remove the child from the facility. (Your child will not be allowed to leave with any other person without authorization from the parent or guardian).

Name Full Address (Street/City/State/Zip) Telephone Relationship

Consent For Medical Treatment

Physician or Dentist to be called in emergency

Past Illnesses - Check any illness the child has had and give an approximate date

Illness Date Illness Date

Does your child have any special problems or fears?

Are the problems serious enough to restrict your child's activities?

Does your child have frequent colds?

Is your child currently taking prescribed medicine?

Is it a chronic illness?

Parent or Guardian agrees for provider to consult with a nurse or a physician in regards to child's health as needed for their clarification. In the event that the provider should have questions regarding the health of my child they may contact one, or more, of the following sources of information.

Permission To Release Information

I understand that during the time my child is enrolled in the facility, the director may be asked for information regarding my child.

Field Trip Permit

Parent's Right to Review Complaints

Parent or Guardian Signature