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Child's Full Legal Name
Date Enrolled
Child's Preferred Nickname
Sex
Birthdate
Address
City
Zip
Phone
Who has legal custody?
Relationship
Address
City
Zip
Phone
Child lives with
Mother's Name
Cell Phone/Pager
Phone
Home Address
City
Zip
Place of Employment
Phone
Address
City
Zip
Father's Name
Cell Phone/Pager
Phone
Home Address
City
Zip
Place of Employment
Phone
Address
City
Zip
Person 1 permitted to remove child
Address
City
Zip
Phone
Relationship to the child
Person 2 permitted to remove child
Address
City
Zip
Phone
Relationship to the child
Is your child related to this provider
If so, how?
Person1 to be notified IN CASE OF EMERGENCY when parent or guardian cannot be reached:
Address
City
Zip
Phone
Cell Phone/Pager
Person2 to be notified IN CASE OF EMERGENCY when parent or guardian cannot be reached:
Address
City
Zip
Phone
Cell Phone/Pager
Child's Physician/Health Care Resource
Phone
Address
City
Zip
Child's Dentist
Phone
Address
City
Zip
Communicable diseases child has had (give dates)
Medicines routinely taken
Does your child have any of the following problems? Earaches
Diabetes
Allergies (specify)
Skin Problems
Eating Problems
Vomiting/Diarrhea
Frequent Sore Throats/Colds
Other Chronic Conditions
 Physical or Mental Disabilities
  List all identifying scars, birthmarks, skin discolorations
            Special needs of child
            Instructions regarding toileting
            Child's habits, fears, etc.
            Any other information that you wish known?
My child’s hours in care are as follows
Meals typically served while in care:
Mother's Email Address:
Father's Email Address: