Form Bcal-3731 - Child Information Record
Download a blank fillable Form Bcal-3731 - Child Information Record in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Bcal-3731 - Child Information Record with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
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,
“unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.
For
Date of Admission
Date of Discharge
Provider
Use Only:
Name of Child (Last, First, Middle Initial)
Child’s Date of Birth
/
Address (Number and Street, Building/Apartment Number)
City
State
Zip Code
Parent/Legal Guardian’s Name
Home Phone
Parent/Legal Guardian’s Name (Optional) Home Phone
(
)
(
)
Home Address (if not child’s address)
Cell Phone
Home Address (if not child’s address)
Cell Phone
(
)
(
)
City
State
Zip Code
City
State
Zip Code
Email Address (optional)
Email Address
Employer Name
Work Phone
Employer Name
Work Phone
(
)
(
)
Name of Child’s Physician or Health Clinic
Physician’s or Health Clinic’s Phone Number
(
)
Hospital Preferred for Emergency Treatment (optional)
Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary.)
BCAL-3731 (Rev. 6-17) Previous editions 4-16, 6-15 and 7-12 may be used until September 30, 2018.
See Reverse Side
Emergency Contact & Release of Child: List all individuals,including parents/legal guardians, in order of preference, to be contacted in an emergency. If
possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The
second phone number column can be left blank. (If more individuals, attach additional sheets.)
1.
(
)
(
)
2.
(
)
(
)
3.
(
)
(
)
Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)
1.
(
)
2.
(
)
3.
(
)
4.
(
)
Parent/Legal Guardian Initials:
I give permission to ___________________________________, licensed by the Department of Licensing and Regulatory Affairs to secure
emergency medical for the above named minor child while in care.
I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form.
Signature of Parent or Guardian
Date Signed
Date Card
Parent or Legal
Date Card
Parent or Legal
Date Card
Parent or Legal
Date Card
Parent or Legal
Reviewed
Guardian Initials
Reviewed
Guardian Initials
Reviewed
Guardian Initials
Reviewed
Guardian Initials
AUTHORITY: 1973 PA 116
LARA is an equal opportunity employer/program.
COMPLETION: Required
PENALTY: Rule Violation
BCAL-3731 (Rev. 6-17) Previous editions 4-16, 6-15 and 7-12 may be used until September 30, 2018.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal