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Child Enrollment and Health Information

Child's Name						Date
Date of Birth	Home Address			City, State, Zip		Telephone

Parent/Guardian		Relationship to child		Parent/Guardian	Relationship to child

Home Address		City, State, Zip		Home Address	City, State, Zip

Employer Information				Employer information

List all phone numbers where you can be reached				List all phone numbers where you can be reached

Which Number should I call 1st?				Which Number should I call 1st?

Emergency Contact Information: List the names of other LOCAL PERSONS who you want to be contacted in the event of
an emergency or illness if either parent/guardian cannot be reached. Persons listed should be able to assist in locating the
parents/guardian and be able to take responsibility for the child in cases where the parent/guardian can not be located.
Name		Phone Numbers		Name	Phone Numbers

Name		Phone Numbers		Name	Phone Numbers

			Emergency Transportation
1. GIVING PERMISSION TO TRANSPORT				2. NOT GIVING PERMISSION TO TRANSPORT
I give Amy Holland my permission to have my child listed				I DO NOT give Amy Holland my permission to have my child
above transported to the Hospital listed below for				listed above transported for emergency medical or dental care.
Emergency medical care or to Dentist listed below for				In the event of an illness or injury which requires emergency
Emergency dental care or to the nearest available source				medical or dental treatment, I wish the following action be taken:
of assistance.
Hospital_________________________________
Dentist__________________________________

Parent/Guardian Signature			Date

Name of Physician

Address		Phone

Name of Dentist				Parent/Guardian Signature		Date

Address	Phone