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Childs Information US

The document is a child information form that collects details about a child such as name, address, birthdate, schedule, parent/guardian information, medical information, physician/dentist details, and requires a parent signature.

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ashishgaur007
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137 views1 page

Childs Information US

The document is a child information form that collects details about a child such as name, address, birthdate, schedule, parent/guardian information, medical information, physician/dentist details, and requires a parent signature.

Uploaded by

ashishgaur007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM

Child Information Form


Childs Name: ________________________________________ Primary Language: ________________________
Childs Address: ______________________________________________________________________________
Street City/Town Zip Code
Place of Birth: _____________________________________________________Date of Birth: _____/_____/_____

Childs Schedule: MON __________ TUE __________ WED __________ THU __________ FRI ___________

Parent/Guardian Information
Name:____________________________________ Name: ________________________________________
Relationship: ______________________________ Relationship: __________________________________
Address: _________________________________ Address: ______________________________________
_________________________________________ ______________________________________________
Home E-mail Address: ______________________ Home E-mail Address: ___________________________
Cell Phone: _______________________________ Cell Phone: ____________________________________
Home Phone: ______________________________ Home Phone: __________________________________
Others in Family Relationship: ____________________________________________________________________
Parent/Guardian Business Information
Company Name: ___________________________ Company Name: ________________________________
Address: _________________________________ Address: ______________________________________
_________________________________________ ______________________________________________
Business Phone: __________________________ Business Phone: _______________________________
E-mail Address: ___________________________ E-mail Address: _________________________________

Medical Information
Eye Color: ______ Hair Color: _______ Height: ______ Weight: ______ Race: ______ Gender M F
Identified Allergies: ____________________________________________________________________________
Identifying Marks: ____________________________________________________________________________
Health Insurance Provider: _____________________________________________________________________
Physician/Dentist Information
Name of Physician/Clinic: ______________________________________ Phone: ________________________
Physician Address: ___________________________________________________________________________
Street City/Town Zip Code
Date of Childs Last Physical (WA State Only): ______________________________________________________
Name of Dentist: _____________________________________________ Phone: ________________________
Dentist Address: _____________________________________________________________________________
Street City/Town Zip Code

Parent/Guardian Signature: _____________________________________ Date: _________________________

FOR CENTER USE: Center: _________________________ Date of Admission________________ Age of Admission: _______________

Date Registration Fee Recd:_________________________ Directors Initials: _________________

Child Information Form: Operations Page 1 of 1


Effective: 06/2015

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