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.
For Provider
Use Only:
Date of Admission Date of Discharge
Name of Child (Last, First, Middle Initial)
Child’s Date of Birth
Address (Number and Street, Building/Apartment Number) City State Zip Code
Parent/Legal Guardian’s Name Home Phone
( )
Parent/Legal Guardian’s Name (Optional) Home Phone
( )
Home Address (if not child’s address) Cell Phone
( )
Home Address (if not child’s address) Cell Phone
( )
City State Zip Code
City
State Zip Code
Email Address (optional) Email Address
Employer Name Work Phone
( )
Employer Name Work Phone
( )
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 (Attach additional sheets, if necessary.)
BCAL-3731 (Rev. 7-18) Previous edition 6-17 may be used. See Reverse Side
Emergency Contact & 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. (If more individuals, attach additional sheets.)
1. ( ) ( )
2. ( ) ( )
3. ( ) ( )
Release of Child Only: List all individuals, otherthan the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)
1. ( ) 2. ( )
3. ( ) 4. ( )
Parent/Legal Guardian Initials:
I give permission to ______________________________, licensed by the Department of Licensing and Regulatory Affairs to secure emergency
medical treatment for the above named minor child while in care.
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
Date Card
Reviewed
Parent or Legal
Guardian Initials
Date Card
Reviewed
Parent or Legal
Guardian Initials
Date Card
Reviewed
Parent or Legal
Guardian Initials
Date Card
Reviewed
Parent or Legal
Guardian Initials
LARA is an equal opportunity employer/program.
AUTHORITY: 1973 PA 116
COMPLETION: Required
PENALTY: Rule Violation Citation.
BCAL-3731 (Rev. 7-18) Previous edition 6-17may be used.
South Olive Christian School