JUST FOR KIDZ!    ADMISSION DATE_______/________/______
                                                                                                                                                                                                                                                                                                                                                                                                                      
(FIRST DAY IN CARE)

CHILD'S NAME_____________________________________            SEX:  M    F            BIRTHDATE:_____________________

ADDRESS_________________________________CITY___________________STATE_________  ZIP__________

MOTHER'S NAME________________________________________PHONE  NUMBERS: _________________/______________

                         DRIVER'S LICENSE # ________________________ST______      SSN  
*   *   *  -  *    *  - ________

FATHER'S NAME________________________________________PHONE NUMBERS: _________________/_______________
                        
                         DRIVER'S LICENSE # ________________________ST______      SSN
 *   *   *  -  *    *  - ________


IN CASE OF EMERGENCY IN WHICH THE PARENTS CANNOT BE REACHED, THE FOLLOWING PERSONS MAY PICK UP MY
CHILDREN:

1)_______________________________________________________________________________________________________
       NAME                                             RELATION                              PHONE NUMBER                                        DL #
2)_______________________________________________________________________________________________________                   NAME                                            
RELATION                              PHONE NUMBER                                        DL #


                                      
       ********* SPECIAL EMERGENCY REFERRAL INSTRUCTIONS*********
IN THE EVENT I CANNOT BE REACHED OR MAKE ARRANGEMENTS FOR EMERGENCY MEDICAL ATTENTION AT THE TIME OF ILLNESS OR
ACCIDENT,
I HEREBY AUTHORIZE _________________________________________________________________TO TAKE MY CHILD TO:
                                                                        NAME OF CHILDCARE FACILITY

1)_________________________________________________________________________________________________________
           DOCTOR NAME                                 ADDRESS                                                                 PHONE #

2)_________________________________________________________________________________________________________
    CLINIC/HOSPITAL                                      ADDRESS                                                                PHONE #


PARENT/GUARDIAN SIGNATURE___________________________________        DATE________________
MY CHILD ATTENDS:

__________________________________________________________________            ______________________
   NAME OF PUBLIC SCHOOL (IF ANY)                                                                                                         TELEPHONE #

MY CHILD'S IMMUNIZATION RECORDS ARE ON FILE AT THE SCHOOL/FACILITY AND ALL IMMUNIZATIONS AND TUBERCULOSIS TEST
RESULTS ARE CURRENT.

                 ______________________________________________                       _____________________
                           SIGNATURE-  PARENT OR LEGAL GUARDIAN                                                 DATE

LIST ANY SPECIAL INSTRUCTIONS FOR YOUR CHILD SUCH AS ALLERGIES, EXISTING ILLNESS, PREVIOUS
SERIOUS ILLNESS, INJURIES DURING THE PAST TWELVE MONTHS, ANY MEDICATION PRESCRIBED FOR
LONG-TERM CONTINUOUS USE, AND ANY OTHER INFORMATION WHICH STAFF SHOULD BE AWARE OF:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


             ________________________________________________                      ______________________
                         SIGNATURE-PARENT OR LEGAL GUARDIAN                                                      DATE
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