Child Care Registration And Emergency Information - Bureau Of Licensing And Certification Page 2
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2CHILD CARE REGISTRATION AND EMERGENCY INFORMATION
NON-EMERGENCY ALTERNATE PICK-UP PERSON/S Continued
Name:
Name:
Relationship:
Relationship:
Address:
Address:
Phone number:
Phone number:
NOTE TO PARENT/S or GUARDIAN/S: The licensing authority for this program is the Bureau of Licensing and
Certification, Child Care Licensing Unit. Child care programs are required to post a copy of the statement of findings and
corrective action plan for the most recent visit in a location which is accessible to parents, and must maintain copies of the
statement of findings and corrective action plan for the preceding visit and make them available for parents to review
upon
request.
Statements
of
findings
and
corrective
action
plans
are
also
available
on-line
at
or by calling the unit at 1-800-852- 3345, extension 9025 or 603-271-9025.
During licensing, monitoring, and complaint investigation visits to licensed programs the department shall speak with
children regarding the care they receive at the program, if in the judgment of the licensing coordinator the children's
response would be valuable in determining compliance with licensing rules. Licensing staff are experienced in working
with children and trained to interview in a manner that is respectful and non-leading. However, if you do not want your
child interviewed, or if you wish to be informed prior to your child being interviewed you must give the family child care
provider, center director, site director or designee, and update annually, a signed dated statement indicating your
preference.
For more information about Child Care Licensing please visit our website at:
MEDICAL INFORMATION
Any chronic conditions, allergies or medications that could be important in case of sudden illness or injury:
Child’s Usual Physician:
Phone number:
Physician’s Address:
EMERGENCY MEDICAL TREATMENT AUTHORIZATION
I hereby give permission for the staff of __________________________________________ to provide simple first aid
treatment to my child, _________________________________________when necessary. In the event of a more serious
illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to
receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as
is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility
to examine and provide emergency medical treatment to my child if warranted. I understand that I will be contacted by
child care program personnel as soon as possible regarding any emergency involving my child.
Parent/Guardian Signature
Date
ANNUAL UPDATE:
PARENT/GUARDIAN MUST REVIEW THIS INFORMATION ANNUALLY, MAKE NECESSARY CHANGES &
INITIAL & DATE BELOW TO VERIFY THAT THE INFORMATION IS CURRENT.
Parent/Guardian Initials:
Date:
Parent/Guardian Initials:
Date:
Parent/Guardian Initials:
Date:
Parent/Guardian Initials:
Date:
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t:\program support\licensing\ccl\group\2008 cc rules\sample forms packet\2008 child care registration and emergency information .doc
03/24/09
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