Child Information Sheet

1. Child's Name _____________________________________ Birth Date _______________________________
2. Child's Name _____________________________________ Birth Date _______________________________
Mother's Name ____________________ Address _________________________ Ph. _____________________
Business Name ____________________ Address _________________________ Ph. _____________________
Father's Name _____________________ Address _________________________ Ph. _____________________
Business Name ____________________ Address _________________________ Ph. _____________________
Behavior:
What method of behavior control is used at home? _________________________________________________
What is child's usual reaction? _________________________________________________________________
How would you describe your child's personality? _________________________________________________
Does your child have any special habits, favorites or fears? _________________________________________
Is your child left or right handed? ______ Does child dress self? ______ Undress self? ______
When did child begin toilet training? _______ Word used for urination? ________  Bowel Movement? _______
Name of other person's to call in an emergency:
Name ________________________ Relationship ___________________ Phone ________________________
Name ________________________ Relationship ___________________ Phone ________________________

List of names of other person's authorized to pick up your child (ren):
Name ________________ Relation _______________ Ph. ___________________ DL # __________________
Name ________________ Relation _______________ Ph. ___________________ DL # __________________
Authorization for Medical Emergencies:
I, ________________________ authorize Treasured Times employees to secure medical/surgical treatment from a physician or hospital for my child (ren), ___________________, ___________________ with hospital preference of _________________________ should it be necessary.  I understand that all reasonable efforts will   be made to notify me before such action is taken and I agree that the expense of such emergency will be accepted and  paid by me.
Health Information:   (Give copy of immunization - see enrollment record card)
Name of Physician _________________________________________ Ph. _________________
Medical Ins. Co. ___________________________________________ Ph. _________________
Address __________________________________________________ Policy # _____________
Name of Insured ___________________________________                               (Give copy of card)
Last physical exam 1._______________________ 2.___________________
Does your child (ren) had allergies? ___________ Describe ____________________________
Signed _________________________________________ Date __________________________
 

 
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