Child's Name:

Home Address (#, Street, City, State, Zip Code):

Home Phone:

Date of Birth:

Sex:

MaleFemale

Mother or Guardian Name:

Home Address (#, Street, City, State, Zip Code):

Cell Phone (optional):

Contact Telephone Number:

Father or Guardian Name:

Home Address (#, Street, City, State, Zip Code):

Cell Phone (optional):

Contact Telephone Number:

I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted:

Name:

Contact Telephone Number:

Name:

Contact Telephone Number:

Name (optional):

Contact Telephone Number:

Name (optional):

Contact Telephone Number:

If Medical care is necessary, call:
Health Care Provider*

Name:

Contact Telephone Number:

*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
By filling out this form I hereby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense of this service will be accepted by me.

In case of injury or sudden illness, I request that this individual be called first:

Does your child have insurance coverage? YesNo

Name of Insurance Company:

The following individual(s) may NOT remove my child from the facility:

Name(s) (optional):

Custody papers have been provided and are on file at the facility? (optional) YesNo
Telephone Authorization Code (optional):

One of the following will be provided at the time of signing this document:

Copy of current official documented immunization recordReligious Beliefs exemption form signed by parent/guardianMedical Exemption form signed by physician and parent/guardianSigned Laboratory Proof of Immunity form

Is child allergic to food or other substances? YesNo

If yes, describe symptoms, name foods or substances to be avoided, and the procedure to follow if reaction occurs:

Is child usually susceptible to infections and if so, what precautions need to be taken? YesNo

If yes, list precautions:

Is child subject to convulsions and what should be our procedure if one occurs? YesNo

If yes, list precautions:

Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, foot problem, hearing impairment, hernia, etc.)? YesNo

If yes, list precautions:

Additional comments:

Other special instructions: