Child Information Record - Michigan
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1CHILD INFORMATION RECORD
State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply,
Date of Admission
Date of Discharge
For Provider
Use Only:
Child’s Date of Birth
City
State
Zip Code
Home Phone
Home Phone
(
)
(
)
Cell Phone
Cell Phone
(
)
(
)
City
State
Zip Code
City
State
Zip Code
Work Phone
Work Phone
(
)
(
)
(
)
See Reverse Side
Emergency Contact & Release of Child:
1.
3.
Release of Child Only:
1.
3.
4.
Parent/legal guardian must initial one of the following:
______I give permission to _____________________________________, licensed by the Department of Licensing and Regulatory Affairs to secure
______I do not give permission to _____________________________________, licensed by the Department of Licensing and Regulatory Affairs to
all emerency medical care.
Date Signed
Date Card
Parent or Legal
Date Card
Parent or Legal
Date Card
Parent or Legal
Date Card
Parent or Legal
Reviewed
Reviewed
Reviewed
Reviewed
.
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