Child's Personal Data Sheet

---

Date of enrollment: ______________ Date of discharge: ________________Grade______________

Child’s Personal Data Sheet 1. Child’s Name:_________________________________________________DOB____/____/____ Primary Caregiver:_____________________________________ Relationship to child:___________________ Home Address:________________________________________ City, State, Zip________________________ Home phone:___________________ Work phone:__________________ Cell phone:_____________________ Place of employment: __________________________________________ Work hours:___________________ E-mail address: ____________________________________________ Secondary Caregiver:___________________________________ Relationship to child:___________________ Home Address:________________________________________ City, State, Zip________________________ Home phone:___________________ Work phone:___________________ Cell phone:____________________ Place of employment: __________________________________________ Work hours:___________________ E-Mail address: _____________________________________________

2. Emergency Contact Information Name of person to call if parents cannot be reached: ________________________________________________________ Address:_____________________________________________________ City, State, Zip__________________________ Home phone:_______________________ Work phone: ______________________Cell phone:_______________________ Is this person authorized to take the child from the center?

Yes________ No________

3. List all other adults who are authorized to take the child from the center: ___________________________________ Name

___________________________ Relationship

_________________________ Phone number

___________________________________ Name

___________________________ Relationship

_________________________ Phone number

___________________________________ Name

___________________________ Relationship

_________________________ Phone number

4. Medical Information: ______________________________________________________ _________________________________ Child’s Physician or emergency treatment facility

Phone number

___________________________________________________________________ Address

_________________________________________ City, State, Zip

I, ______________________________________________________, mother / father / guardian (circle one) of ________________________________________________, do hereby give my consent to the Director of the (Child’s name)

Child Care Facility, or his duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached. Consent is also given for the Director or his duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached.

___________________________________________________ Signature of caregiver

___________________ Date

_________________________________________________________ ______________________ Witness

Date

5. Consents I hereby give_____/do not give_____ written permission for the use of suntan lotions/sunscreen for my child in permit able weather. In accordance with Minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 1101.16. Signature:____________________________________________________________

Date: _______________________

6. Acknowledgments This is a statement of verification that I have been informed that child care licensing/child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes. This is in accordance with Minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 201.4. Signature: _____________________________________________________________

Date: ______________________

This is to acknowledge that that I have received a list of Kindergarten Readiness Skills for my child (3 and 4YO children only). This is in accordance with Minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 201.5 Signature: ______________________________________________________________ Date: ______________________

This is a statement of verification that I have been informed of the behavior guidance policy practiced. Signature: ______________________________________________________________ Date: _______________________

7. Pertinent Medical and Developmental Information Immunizations: I have provided a copy of my child’s Immunization Record: Yes_____________

No _______________

Disease history: Measles _______ Mumps______German Measles________Chicken Pox_____Whooping Cough________

Contracted Tuberculosis: Yes____No____ Frequent ear infections:Yes____No____ Defective heart: Yes____No____ Frequent throat infections: Yes___No___ Seizures: Yes___ No____ Sun Sensitivity: Yes____ No___ Frequent colds: Yes____No____ Diabetes: Yes___ No____ Fainting spells: Yes____No____ Temper tantrums: Yes____ No____ Biting: Yes _____ No____ Allergies:______________________________________________Medications: ___________________________________ Physical or emotional concerns child might have____________________________________________________________ Other conditions or comments: __________________________________________________________________________ Special food needs: Formula_____________________Diabetic diet____________________Other____________________ Is child toilet-trained: Yes_______No_______

Words used in toileting_________________________________________

Siblings? Yes____ No____ Name(s) of siblings:____________________________________________________________

8. I, the parent/guardian of this child, understand that I may ask for a conference with the caregiver(s) as needed. Signature:_________________________________________________ Date:____________________ Additional Comments: ________________________________________________________________________________ ___________________________________________________________________________________________________