Child Information Record (BCAL-3731 Rev. 7-18)
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 response required. A blank field, a line through a field or "N/A" are NOT acceptable responses.

ONE FORM PER CHILD

For Provider Use Only: Date of Admission Date of Discharge
Name of Child *
Last Name, First Name, Middle Initial
Child's Date of Birth *
MM/DD/YY
Child's Address (Number and Street, Building/Apartment Number, City, State, Zip Code) *
Child's Complete Mailing Address
(First) Parent/Legal Guardian's Name (REQUIRED) *
First & Last Name
(First Parent) Home Phone # (If NONE, please write NONE) *
(First Parent) Personal Cell Phone # *
Include Area Code with Cell Phone #
(First Parent) Home Address (if different than child's address) including House Number, Street Name, City, State, Zip Code (If SAME as child's, write SAME) *
(First Parent) Email Address *
Email Address including extension (.com, .net, .edu, etc.)
(First Parent) Employers Name *
(First Parent) Work phone # *
Include area code with work phone # and extension if applicable
(Second Parent) Parent/Legal Guardian's Name (OPTIONAL)
First & Last Name
(Second Parent) Home Phone # (If NONE, please write NONE) (OPTIONAL)
(Second Parent) Personal Cell Phone # (OPTIONAL)
Include Area Code with Cell Phone #
(Second Parent) Home Address (if different than child's address) including House Number, Street Name, City, State, Zip (If SAME as child's, write SAME) (OPTIONAL)
(Second Parent) Email Address (OPTIONAL)
Email Address including extension (.com, .net, .edu, etc.)
(Second Parent) Employer Name (OPTIONAL)
(Second Parent) Work phone # (OPTIONAL)
Include area code with work phone # and extension if applicable
Name of Child's Physician or Health Clinic *
Physician or Health Clinic's Phone # *
Hospital preferred for Emergency Treatment (Optional)
Clear selection
Allergies, Special Needs and Special Instructions: *
Required
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