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Emergency Card
  • 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 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.
  • Release of Child Only: List all individuals, other than parents / legal guardians, to whom the child may be released.
  • Parent / Legal Guardian Initials:
  • I certify that I accurately completed this form and if anything changes, I will notify the provider by updating this form.