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Name of Childcare Center:___________________________________________________

Address of Center:_________________________________________________________

Center Phone Number :_____________________________________________________

Caregiver Name:___________________________________________________________

Child's Full Name:_________________________________________________________

Hair Color:________________________   Eye Color:_____________________________

Child's Date of Birth:________________   Home Phone:__________________________

Home Address:___________________________________________________________

Mother's Name:___________________________________________________________

Daytime Phone:________________________ Work Phone:_______________________

Father's Name:____________________________________________________________

Daytime Phone:________________________ Work Phone:________________________

Emergency Contact Name:__________________________________________________

Daytime Phone:_________________________ Work Phone:_______________________

Child's Primary Care Physician:______________________________________________

Office Phone:_____________________ Hospital of Choice:________________________

Medical Card #:_______________________ Child's Personal ID #:__________________

Allergies:_________________________________________________________________

Medical Conditions:________________________________________________________

Medications taken daily:____________________________________________________