identification and emergency information child care centers/family child care homes

Subject *

Tags

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE

CHILD’S NAME LAST

MIDDLE

FIRST

SEX

TELEPHONE

ADRESS

NUMBER STREET

CITY

STATE

ZIP

BIRTHDATE

PARENT / AUTHORIZED REPRESENTATIVE LAST NAME

MIDDLE

FIRST

BUSINESS TELEPHONE

HOME ADRESS

NUMBER STREET

CITY

STATE

ZIP

HOME TELEPHONE

PARENT / AUTHORIZED REPRESENTATIVE LAST NAME

MIDDLE

FIRST

BUSINESS TELEPHONE

HOME ADRESS

NUMBER STREET

CITY

STATE

ZIP

HOME TELEPHONE

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

ADRESS

TELEPHONE

RELATIONSHIP

PHYSICIAN

ADRESS

MEDICAL PLAN AND NUMBER

TELEPHONE

DENTIST

ADRESS

MEDICAL PLAN AND NUMBER

TELEPHONE

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

CALL EMERGENCY HOSPITAL

OTHER

EXPLAIN

PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

RELATIONSHIPS

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES