* = Required Information
INSTRUCTIONS TO PARENTS:
(1) Complete all items on this side of the form. Sign and date where indicated.
(2) If your child has a medical condition which might require emergency medical care, complete the back side of the form. If necessary, have your child's health practitioner review that information.

NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY
When parents cannot be reached, list at least one person who may be contacted to pick up the child in an emergency:
1. Name *
  Last First
Telephone * (H) (W)
Address *
  Street/Apt.# City State Zip Code
2. Name
  Last First
Telephone (H) (W)
Address
  Street/Apt.# City State Zip Code
3. Name
  Last First
Telephone (H) (W)
Address
  Street/Apt.# City State Zip Code
Child's Physician or Source of Health Care Telephone
Address
  Street/Apt.# City State Zip Code
In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to that hospital.
Name of Parent/Guardian Date
Child's Name Birth Date
  Last First
Enrollment Date Hours & Days of Expected Attendance
Child's Home Address
  Street/Apt.# City State Zip Code
Mother's Name Home Telephone
  Last First
Mother's Employer/School
  Name Address
Mother's Home Address
(If different from above)
  Street/Apt.# City State Zip Code
Work Telephone Cellular Phone Beeper
Father's Name Home Telephone
  Last First
Father's Employer/School
  Name Address
Father's Home Address
(If different from above)
  Street/Apt.# City State Zip Code
Work Telephone Cellular Phone Beeper
Name of Person Authorized
to Pick Up Child (daily)
  Last First Relationship to Child
Address
  Street/Apt.# City State Zip Code
ANNUAL UPDATES
  (Initials/Date) (Initials/Date) (Initials/Date) (Initials/Date)
INSTRUCTIONS TO PARENT:
(1) Complete the following items, as appropriate, if your child has a condition(s) which might require emergency medical care.
(2) If necessary, have your child's health practitioner review the information you provide below and sign and date where indicated.
Child's Name: Date of Birth:
Medical Condition(s):
Medications currently being taken by your child:
Date of your child's last tetanus shot:
Allergies/Reactions:
EMERGENCY MEDICAL INSTRUCTIONS:
(1) Signs/symptoms to look for:
(2) If signs/symptoms appear, do this:
(3) To prevent incidents:
Other special medical procedures that may be needed:
Comments: