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Get Dhr Cdc 739 2006-2024

Print Form H. Child s preadmission record DHR-CDC-739 Revised 1/06 CHILD S PREADMISSION RECORD This section is to be completed by the child s parent or guardian. This form must be kept in the child s file in the Child Care Facility home/center. Child s Name Name child is known by Child s birthdate Child s home address Name s of parent s /guardian s Home telephone number Address of parent s /guardian s Mother s employer Employer s address Employer s telephone number List telephone numbers such as beeper cellular phone etc* Instructions regarding how parent/guardian may be reached in an emergency Person s to be contacted in an emergency if parent s /guardian s cannot be reached Name Relationship to child Address Telephone number Name of child s doctor Emergency Authorization I give permission for the child care facility to obtain emergency medical treatment including emergency transportation for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred* If parent/guardian refuses to sign instructions must be attached stating what procedure the facility is to follow in an emergency. / Signature Date Form not valid without signature of child s parent/guardian Page one of two-form not valid without second page Effective January 22 2001/Reprinted January 2006 Describe any special needs or instructions below Person s the child may be released to I understand that the Department of Human Resources does not inspect activities away are facility home or center. The licensee of the child care facility from the child ccare assumes full responsibility for such activities. Signature of parent/guardian Circle yes or no and sign each line Activities away from the facility Swimming/wading activities provided by yes no Child s first day of attendance Child s withdrawal date Additional information may be attached*. Child s Name Name child is known by Child s birthdate Child s home address Name s of parent s /guardian s Home telephone number Address of parent s /guardian s Mother s employer Employer s address Employer s telephone number List telephone numbers such as beeper cellular phone etc* Instructions regarding how parent/guardian may be reached in an emergency Person s to be contacted in an emergency if parent s /guardian s cannot be reached Name Relationship to child Address Telephone number Name of child s doctor Emergency Authorization I give permission for the child care facility to obtain emergency medical treatment including emergency transportation for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred* If parent/guardian refuses to sign instructions must be attached stating what procedure the facility is to follow in an emergency. I agree to be responsible for any emergency medical expenses incurred* If parent/guardian refuses to sign instructions must be attached stating what procedure the facility is to follow in an emergency. / Signature Date Form not valid without signature of child s parent/guardian Page one of two-form not valid without second page Effective January 22 2001/Reprinted January 2006 Describe any special needs or instructions below Person s the child may be released to I understand that the Department of Human Resources does not inspect activities away are facility home or center. .

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