Child's Name *

First Name

Last Name

Child's Birthdate *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Doctor

First Name

Last Name

Doctor's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Doctor's Phone Number

(###)

###

####

1. Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Employer's Phone *

(###)

###

####

2. Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Employer's Phone

(###)

###

####

Emergency Authorization

I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

I agree

I do not agree

I understand that the Department of Human Resources does not inspect activities away from the child care facility. The licensee of the child care facility assumes full responsibility for such activities.

I agree

Today's Date

MM

DD

YYYY

I give permission for my child to participate in: *

Activities away from the facility

Transportation provided by the facility

Swimming/wading activities provided by the facility

Today's Date

MM

DD

YYYY