Child Information Card State of Delaware Department of Services for Children, Youth, and Their Families Child’s Information Child’s name: Date of birth: Date of enrollment: Date of discharge: Child’s address: Hours and days child is scheduled to attend: Parent/Guardian Information (1) Parent/Guardian Information (2) Emergency Contact/Authorized to Pick-up Child Emergency Contact/Authorized to Pick-up Child Name: Name: Address, if different from child’s: Address, if different from child’s: Home phone: Cell phone: Home phone: Cell phone: Work phone: Hours of employment: Work phone: Hours of employment: Employer name and address: Employer name and address: Additional Emergency Contacts and People Authorized to Pick-up Child Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Emergency Medical Care I, _____________________________, the parent (or legal guardian) of _____________________________, who is my minor child, hereby authorize emergency medical treatment for my child in the event I cannot be contacted to give permission to treat. I understand I will be financially responsible for the cost of such treatment. Transportation I, _____________________________, the parent (or legal guardian) of _____________________________, who is my minor child, hereby give permission for my child to be transported by the licensee/staff/substitute. _____________________________ _____________________________ Signature of parent/guardian Date Medical Information Name of child’s physician: Office phone: Special medical information, medications, allergies, diet: Health insurance identification information: The above information is necessary for your child’s protection and this facility is required to have it. Keep this information current.
Child Information Card State of Delaware Department of Services for Children, Youth, and Their Families Child’s Information Child’s name: Date of birth: Date of enrollment: Date of discharge: Child’s address: Hours and days child is scheduled to attend: Parent/Guardian Information (1) Emergency Contact/Authorized to Pick-up Child Parent/Guardian Information (2) Emergency Contact/Authorized to Pick-up Child Name: Name: Address, if different from child’s: Address, if different from child’s: Home phone: Cell phone: Home phone: Cell phone: Work phone: Hours of employment: Work phone: Hours of employment: Employer name and address: Employer name and address: Additional Emergency Contacts and People Authorized to Pick-up Child Name: Address: Phone: Name: Address: Phone: Name: Address: Phone: Emergency Medical Care I, _____________________________, the parent (or legal guardian) of _____________________________, who is my minor child, hereby authorize emergency medical treatment for my child in the event I cannot be contacted to give permission to treat. I understand I will be financially responsible for the cost of such treatment. Transportation I, _____________________________, the parent (or legal guardian) of _____________________________, who is my minor child, hereby give permission for my child to be transported by the licensee/staff/substitute. _____________________________ Signature of parent/guardian _____________________________ Date Medical Information Name of child’s physician: Office phone: Special medical information, medications, allergies, diet: Health insurance identification information: The above information is necessary for your child’s protection and this facility is required to have it. Keep this information current.
fcch-lfcch-child-information-card.docx