CHILD INFORMATION RECORD
- State of Michigan - Department of Licensing and Regulatory Affairs - Child Care Licensing
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.
Physician / Health Clinic Information
Emergency Contact and Release of Child: List all individuals, including parents / legal guardians, in order of preference, to be contacted in an emergency. If possible, include one person other than the parent / legal guardian to be contacted in case of emergency and to whom the child can be released. The second phone number column can be left blank.
Release of Child Only: List all individuals, other than parents / legal guardians, to whom the child may be released.
Parent / Legal Guardian consent and signature:
- I GIVE PERMISSON to Shine Summer Day Camp , licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical and/or emergency surgical treatment for the above name minor child while in care.
I GIVE PERMISSON for my child to be transported to and from scheduled field trips during the week(s) my child is enrolled, and to use their photos on social media, the web site, and in promotional materials.
Should a medical emergency arise, the leaders HAVE MY PERMISSON to obtain any necessary medical care for my child. I agree to defend and indemnify
Ward Evangelical Presbyterian Church, its employees and volunteers against any claim or action that might arise on behalf of myself or my child, other than for the willful, wanton or reckless misconduct of Ward Evangelical Presbyterian Church, its employees or volunteers.