Voluntary Registration Program Children'S Record printable pdf download

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Model Form

Division of Licensing Programs

VOLUNTARY REGISTRATION PROGRAM

CHILDREN’S RECORD

_____________________________________________________

____________________

Full Name of Child: _______________________________________ Nickname: ___________________

Address of Child

______________________________________________________________________

Date of Birth: ____/____/____

Date of Enrollment: ____/____/____

Date of Withdrawal: ____/____/___

* Proof of Identity:

Place of Birth

Birth Date

Birth Certificate Number

Date Issued

Other form of Proof

Birth Date

Date Documentation Viewed

Person Viewing Documentation

Previous Schools and Daycare attended: ______________________________________________________

________________________________________________________________________________________

Date of Notification of Local Law Enforcement Agency (when required proof of identity is not provided within 7 days of

enrollment.) ______________________________

Parent/Guardian Information

Mother’s Name: _________________________________________________________________________

Mother’s Address: ________________________________________________________________________

Mother’s Home Phone Number: _____________________________________________________________

Mother’s Employer: ______________________________________________________________________

Mother’s Employer’s Address: _______________________________________________________________

Mother’s Work Phone Number: ___________________________

Work Hours: ___________________

Father’s Name: ____________________________________________________________________________

Father’s Address: ___________________________________________________________________________

Father’s Home Phone Number: _________________________________________________________________

Father’s Employer: ___________________________________________________________________________

Father’s Employer’s Address: ___________________________________________________________________

Father’s Work Phone Number: ______________________________

Work Hours: ______________________

CHILD’S MEDICAL INFORMATION

Physician’s Name: ______________________________________________________________________________

Physician’s Address: ____________________________________________________________________________

Physician’s Phone Number: _______________________________________________________________________

Hospitalization/Insurance Information:

Name of Policy: _________________________________________________________________________________

Policy Number: _________________________________________________________________________________

Name of Insured: ________________________________________________________________________________

List the child’s known or suspected allergies or any chronic or recurrent diseases or disabilities (include any known drug

allergies and if so, detailed directions for giving medicines to the child):

____________________________________________________________________________________________________

___________________________________________________________________________________________________

* Proof of identity may be a certified copy of the child’s birth certificate, birth registration card, notification of birth, passport, copy of placement

agreement or other proof from a child-placing agency, record from a public school in Virginia, certification by a principal of a public school in the U.S.

that a certified copy of the child’s birth record was previously viewed. For additional information contact the contract agency.

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