MCA - Head Start - Child Information Record

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.

Name of Child (Last, First, Middle Initial)

Child’s Date of Birth

Date

Address

Address (Number and Street, Building/Apartment Number)

Street Address Line 2

CityState

Zip Code

Parent/Legal Guardian’s Name

Primary Phone

Home Address (if not child's address)

City

State

Zip Code

Email Address (optional)

example@example.com

2nd Phone (if applicable)

Employer Name

Work Phone

Parent/Legal Guardian’s Name (Optional)

Primary Phone (Optional)

Home Address (if not child's address)

City

State

Zip Code

Email Address (optional)

example@example.com

2nd Phone (if applicable)

Employer Name

Work Phone

Name of Child’s Physician or Health Clinic

Physician Phone Number

Please enter a valid phone number.

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and/or Special Instructions

YesNo

If yes, explain

Attach additional sheets, if necessary

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets

1. Name

1. Phone Number

1. Second Phone Number

2. Name

2. Phone Number

2. Second Phone Number

Please enter a valid phone number.

3. Name

3. Phone Number

Please enter a valid phone number.

3. Second Phone Number

Please enter a valid phone number.

Release of Child Only: List all individuals, other than the parents/legal guardian, to whom the child may be released. (If more individuals, atttach additional sheets).

1. Name

1. Phone Number

Please enter a valid phone number.

2. Name

2. Phone Number

Please enter a valid phone number.

3. Name

3. Phone Number

Please enter a valid phone number.

4. Name

4. Phone Number

Please enter a valid phone number.

Parent/Legal Guardian Initials: Please initial that you give permission to the provider, licensed by the Department of Licensing and Regulatory Affairs to secure emergency medial treatment for the above named minor child while in care.

Please initial that you give permission to

Provider Name

I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form.

Signature of Parent or Guardian

Date signed

Date

Teacher

Center

Name of Child (Last, First, Middle Initial)

Child's Date of Birth

Date

Home Phone Number

(In parental/custodial arrangements, court papers MUST be on file to honor your request)

PER PARENT REQUEST DO NOT RELEASE CHILD TO

Name

Relationship to Child

Court Papers on File:

Yes

No

PER PARENT REQUEST DONOT RELEASE CHILD TO

Relationship to Child

Court Papers on File:

Yes

No

PER PARENT REQUEST DONOT RELEASE CHILD TO

Relationship to Child

Court Papers on File:

Yes

No

If there is additional information you deem pertinent to the well-being of your child while in care, please share below: