Registration/Child’s Record

CHILD’S RECORD (This record is for an individual child)

Please list on the back or on an attached sheet of paper a summary record of significant factors concerning the child’s adjustment in the family child care program, unusual events and occurrences.

Admission Date:

Discharge Date: 


Name of Child:

Birthdate:           Gender:

Legal residence: 


#1 Child’s Parent/Legal Guardian’s Name: 

Address, if different from above: 

Place of Employment: Telephone: 

Employment (physical) Address:  

Cell/Home phone:  Work Phone:  

If a child’s parent/legal guardian cannot be reached by telephone during the time the child is in care, how can they be reached? 


#2 Child’s Parent/Legal Guardian’s Name: 

Address, if different from above: 

Place of Employment: Telephone: 

Employment (physical) Address:  

Cell/Home phone:  Work Phone:  

If a child’s parent/legal guardian cannot be reached by telephone during the time the child is in care, how can they be reached? 


Country Fun Child Care MUST be notified by the child’s parent/legal guardian when regular transportation or pick-up methods will vary.


Name and relationship of persons who are to be permitted to remove the child from Country Fun Child Care:

1)

2)


The name, address, telephone number and relationship of a person other than the child’s parents/legal guardians to be contacted if a child’s parents/legal guardians cannot be reached in an emergency:

1)

2)


Name, Address, and Telephone number of family physician: 

Name, Address, and Telephone number of family dentist: 


MEDICAL INFORMATION (This authorization can be replaced with the separate Emergency Medical Authorization. If it is provider will make note of that here: .)


“I hereby give my consent, in the event of a medical emergency when I cannot be contacted, for child care staff to obtain whatever treatment may be deemed necessary for:

Child’s name:

D.O.B.:

Known allergies:

Known medical problems:

This authorization includes my consent for the above named child to receive treatment by a physician in any hospital emergency department.

I hereby give my authorization for emergency medical treatment as outlined above.

Child’s Parents/ Legal Guardians’ signature:

Provider’s Signature (as witness):

Date: