Child Care Registration And Emergency Information - Bureau Of Licensing And Certification

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CHILD CARE REGISTRATION AND EMERGENCY INFORMATION
_________________________________________________________________
____________________
NAME OF CHILD CARE PROGRAM
LICENSE NUMBER
TO THE PARENT OR GUARDIAN: This form must be completed for each of your children who will be enrolled in
the program, and must be updated whenever information changes. You must also either complete a new form annually, or
update this form annually by following the instructions at the bottom of the reverse side of this form.
DATE OF CHILD’S ENROLLMENT ___________________
Child’s name:
Date of birth:
Address:
Phone number:
IDENTIFYING INFORMATION OF PARENT/S OR GUARDIAN/S LEGALLY RESPONSIBLE FOR CHILD:
Name:
Name:
Address:
Address
Home phone number:
Home phone number:
Indicate where parent/guardian above can be reached while child is in care. Include name, address and phone number of
business if applicable. Include any special instructions, e.g. pager, cell phone, etc.
Business Name:
Business Name:
Address:
Address
Phone number:
Hours:
Phone number:
Hours:
Special Instructions for reaching parent/guardian:
EMERGENCY CONTACT PERSON: You (parent/guardian) are required to list at least 1 person with whom you
would feel comfortable leaving your child, and who could assume responsibility for your child if you could not be reached
immediately in an emergency, or if for some reason you could not pick up your child and were unable to communicate
with the program. Examples: if your child were sick and you were not accessible, or if you experienced sudden illness
between work and picking up your child.
Name:
Name:
Relationship:
Relationship:
Address:
Address:
Phone number:
Phone number:
NON-EMERGENCY ALTERNATE PICK-UP PERSON/S: I,_____________________________________________
(Parent/Guardian Signature)
Date Signed
authorize the following individual(s) to pick up my child from the program on a non-emergency basis.
Name:
Name:
Relationship:
Relationship:
Address:
Address:
Phone number:
Phone number:
(7)

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