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.