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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
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
PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
RELATIONSHIP
PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY
RELATIONSHIP
Submit