Child Enrollment Packets Child EnrollmentIDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES To Be Completed by Parent or Authorized RepresentativeChild InformationFirst NameMiddle NameLast NameGender Male Female Prefer Not to AnswerPhone/MobileBirthday DateAddressAddress Line 1Address Line 2CityStateZip CodeParent Authorized InformationFirst NameMiddle NameLast NameAddressAddress Line 1Address Line 2CityStateZip CodeBusiness Phone #Personal Phone #Responsible Person For ChildFirst NameMiddle NameLast NameBusniess Phone #Personal Phone #Additional person who may be called for an Emergency Repeater Field Name Address Telephone Relationship Physician and Dentist to be call for EmergencyPhysicianAddressMedical Plan and NumberPhone/MobileDentistAddressMedical Plan and NumberPhone/MobileIF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHEREXPLAINNAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTENAUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE) Authorized Persons Name Relationship Time Child Will be picked upSubmit Form
