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
Format: (000) 000-0000.
Child's Residential Address

NUMBER

STREET

CITYSTATE

ZIP
Child's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Name

First NameMiddle NameLast Name
Parent / Guardian Phone Number
Format: (000) 000-0000.
Parent / Guardian Address

NUMBER

STREET

CITYSTATE

ZIP
Parent / Guardian Home Phone Number
Format: (000) 000-0000.
Do you need to add a Parent / Authorized Representative?
Parent / Guardian Name

First NameMiddle NameLast Name
Parent / Guardian Phone Number
Format: (000) 000-0000.
Parent / Guardian Home Address

NUMBER

STREET

CITYSTATE

ZIP
PERSON RESPONSIBLE FOR CHILD

First NameMiddle NameLast Name
HOME TELEPHONE
Format: (000) 000-0000.
BUSINESS TELEPHONE
Format: (000) 000-0000.

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.Format: (000) 000-0000.
DENTIST
ADDRESS OF DENTIST
MEDICAL PLAN & NUMBER
DENTIST PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

Other
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
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Signature
Should be Empty:

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