Child Information Record - Dexter Community Schools
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1CHILD INFORMATION RECORD
State of Michigan Department of Human Services - Bureau of Children and Adult 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 fi eld, a line through a fi eld or “N/A” are not acceptable responses.
For Provider
Date of Admission
Date of Discharge
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
Father/Legal Guardian’s Name
Home Phone
Mother/Legal Guardian’s Name
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 (optional)
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. 7-12) Previous editions 9-09, 3-08, 10-07, & 1-06 may be used until 12/31/13.
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.
(
)
I give permission to
, licensed by the Department of Human Services
(Provider’s Name)
to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care.
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
Department of Human Services (DHS) will not discriminate against any individual or group because of race,
AUTHORITY: 1973 PA 116
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or
COMPLETION: Required
expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans
PENALTY: Rule Violation Citation.
with Disabilities Act, you are invited to make your needs known to a DHS offi ce in your area.
BCAL-3731 (Rev. 7-12) Previous editions 9-09,3-08, 10-07, & 1-06 may be used until 12/31/13.
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