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.

Name of Child*

Child's Date of Birth*

Address*

Street Address City State ZIP Code

Parent / Legal Guardian's Name*

Home Phone*

Cell Phone*

Home Address (if not child's address)

Street Address City State ZIP Code

Email (optional)

Employer Name*

Work Phone*

Parent / Legal Guardian's Name (Optional)

Home Phone

Cell Phone

Home Address (if not child's address)

Street Address City State ZIP Code

Email

Employer Name

Work Phone

Physician / Health Clinic Information

Name of Child's Physician or Health Clinic*

Physician's or Health Clinic's Phone Number*

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and Special Instructions (optional)

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.

1) Emergency Contact Name*

Phone #1*

Phone #2

2) Emergency Contact Name

Phone #1

Phone #2

3) Emergency Contact Name

Phone #1

Phone #2

Release of Child Only: List all individuals, other than parents / legal guardians, to whom the child may be released.

1) Name*

Phone #*

2) Name

Phone #

3) Name

Phone #

4) Name

Phone #

Parent / Legal Guardian Initials:

I give permission to SHINE SUMMER DAY CAMP, licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while in care.*

Enter initials above

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*

Digital Signature Acknowledgement*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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