J4TH LIC 700: Identification and Emergency Information

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES
To Be Completed by Parent or Authorized Representative
Child's Name*

First NameMiddle NameLast Name
Child's Sex*
Parent / Guardian Phone Number*
Child's Residential Address*

NUMBER

STREET

CITYSTATE

ZIP
Child's Birthdate*

MonthDayYear
Date
Parent / Guardian Name*

First NameMiddle NameLast Name
Parent / Guardian Phone Number*
Parent / Guardian Address*

NUMBER

STREET

CITYSTATE

ZIP
Parent / Guardian Home Phone Number*
Do you need to add a Parent / Authorized Representative?*

YesNo
Parent / Guardian Name*

First NameMiddle NameLast Name
Parent / Guardian Phone Number*
Parent / Guardian Home Address*

NUMBER

STREET

CITYSTATE

ZIP
PERSON RESPONSIBLE FOR CHILD*

First NameMiddle NameLast Name
HOME TELEPHONE*
BUSINESS TELEPHONE*

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY*

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN*
ADDRESS OF PHYSICIAN*
MEDICAL PLAN & NUMBER*
PHYSICIAN PHONE NUMBER*
Please enter a valid phone number.
DENTIST*
ADDRESS OF DENTIST*
MEDICAL PLAN & NUMBER*
DENTIST PHONE NUMBER*
Please enter a valid phone number.
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?*

CALL EMERGENCY HOSPITALOther
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE*

TIME CHILD WILL BE PICKED UP*

Hour Minutes

AM/PM Option
Parent / Guardian Email*
You will receive a copy of this PDF you just filled out thru this email address.
DATE*

MonthDayYear
Date
Parent / Guardian Signature*

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