Child’s Record Name Of Child: ______________________________ Birthdate: ________________________ Street Address: _________________________________ City:___________________ State:___ Father’s Name____________________________________ Cellphone: (____)_______________ Street Address: (If different from above) _____________________________________ City:_________________________State:_______ Place of Employment: _______________________________ Work Phone: (____)___________ Employment (physical address) _____________________________________ City:_________________________State:_______ Mother’s Name___________________________________ Cellphone: (____)_______________ Street Address: (If different from above) _____________________________________ City:_________________________State:_______ Place of Employment: _______________________________ Work Phone: (____)___________ Employment (physical address) _____________________________________ City:_________________________State:_______ Name, Address and Telephone Number to Next-of-Kin other than parents:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If Parent cannot be reached by telephone during the time the child is in care, how can the parent been reached?__________________________________________________________________ Name, address and telephone number of a person other than the parent to be contacted in case the parent can not be reached in an emergency ________________________________________________________________________________________________ Name of persons who are to be permitted to remove the child from the center: ___________________________________________________________________________________________________________________________________________________________________________ Name, address and telephone number of family physician: _______________________________ ______________________________________________________________________________ Name, address and telephone number of family dentist: _________________________________ ______________________________________________________________________________
MaineLy management must be notified by the parent when regular transportation or pick-up methods will vary.
MEDICAL INFORMATION I, (name) __________________________ hereby give my consent, in the event of medical emergency when I cannot be contacted, for MaineLy Childcare staff to obtain whatever treatment may be deemed necessary for my son/daughter (child’s name) ___________________________(DOB)___________________________________ This authorization includes my consent for the above-named child to receive treatment by a physician in any hospital emergency department. I hereby give my authorization for emergency medical treatment as outlined above. Known Allergies: ________________________________________________________________ Known Medical Problems:_________________________________________________________ Last Tetanus shot: ________________________________ Please list here (or on an additional sheet of paper if necessary) a summary of significant factors concerning the child’s adjustment into group care, unusual events and occurrences or any other information that will help us in transitioning your child into group care : ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I have read and understand the parent handbook, and if I have questions, I know I can always ask the Directors to get clarification. In addition I understand that I can access the Parent Handbook at all times on the MaineLy Childcare website: www.mainelychildcare.com _____________________________________ ______________________________________(Parent or Guardian Name Printed) (Date)
______________________________________(Parent or Guardian Signature)
Office Use Only: Admission Date:_______________________ Discharge Date:___________________________
