Form Cred-0364 - Children'S Record
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2Division of Public Health - Licensure Unit - Children’s Services Licensing Program
Children's Record
PARENTS: PLEASE FILL IN ALL BLANKS
Child(ren)'s Name: _________________________________
Birthdate(s): _____________________________________
Enrollment Date:____________________ Updates:__________________ Date Care Ceased: _______________________
Parent or Guardian's Home Address and Employment Address:
FATHER (or Guardian):
Name: __________________________________________
Employer: _______________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
MOTHER (or Guardian):
Name: __________________________________________
Employer: _______________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
Person(s) to Whom the Child(ren) may be Released by the Caregiver: (If no one, please write "none")
Name: __________________________________________
Name: _________________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
Name: __________________________________________
Name: _________________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
Person(s) Who Will Take Responsibility for the Child(ren) in an Emergency When the Parent (or Guardian) Cannot be
Reached: (ONE NAME MUST BE GIVEN)
Name: __________________________________________
Name: _________________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
Name: __________________________________________
Name: _________________________________________
Address:_________________________________________
Address: ________________________________________
City: ______________________
Phone: _____________
City: ______________________
Phone: _____________
CRED-0364 4/13 (52044)
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Parent category: Legal