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CHILD'S DETAILS

Name

Date of Birth

Street Address

City

State/Province

ZIP / Postal Code

FIRST PARENT

Name

Phone

Email Address

Street Address

City

State/Province

ZIP / Postal Code

SECOND PARENT

Name

Phone

Email Address

Street Address

City

State/Province

ZIP / Postal Code

List all persons authorized to pick up the child from Kids Club. Include parent names!

Person-1

Name

Phone

Person-2

Name

Phone

Person-3

Name

Phone

Local Emergency Contact Person (other than parent):

Name

Phone

Medical Facility & Doctor Name

Phone

Does your child have medical needs?YesNo

If yes, please explain your child's needs. Please include all allergies and any other special emergency care instructions or medical information needed by the child care staff.

Does our child have an allergies?YesNo

If Yes. please list. and indicate type of reaction

Food

Reaction

Medication

Reaction

Insects

Reaction

Does your child suffer from any other allergies, eg. Chemical, first aid creams/lotions, plants, animals?YesNo