Imaginations Learning Academy
Child Biography
Child’s Full
Name: _____________________________________________
Birth Date: _______________________
Address:
_______________________________________________________________________________________
Home Phone: ________________________________ Nickname: __________________________________________
Social
Security: ___________-___________-__________
Mother’s Full
Name:
_____________________________________________________________________________
Home Phone: ____________________________ Work Phone: __________________________ Ext. _____________
Address:
_____________________________________________ Pager/Cellular Phone#: _____________________
Name of
Employer:
______________________________________ Occupation: ______________________________
Business Address/Location:
__________________________________________________________________________
Work Hours: _____________________________________ Driver’s License #: ______________________________
Father’s Full
Name: ______________________________________________________________________________
Home Phone: ____________________________ Work Phone: ____________________________ Ext. ____________
Address:
_____________________________________________ Pager/Cellular Phone#: _____________________
Name of
Employer:
______________________________________ Occupation:
______________________________
Business
Address/Location:
__________________________________________________________________________
Work Hours: _____________________________________ Driver’s License #: ______________________________
Parent/Guardian
with legal custody:
_________________________________________________________________
Parents are: Married _____ Living
Together_____ Divorced _____ Separated _____ Widowed _____ Single _____
Sibling Names
& Ages: __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Emergency
Contacts must be within 20-mile radius of daycare and be someone other than
parent or legal guardian that is over the age of 18.
Primary
Emergency Contact: ______________________________________________________________________
Relationship
to Child:
_______________________________ Work Phone:
___________________ Ext. __________
Address:
____________________________________________________ Home Phone: _______________________
Secondary Emergency Contact:
___________________________________________________________________
Relationship
to Child:
_______________________________ Work Phone:
___________________ Ext. __________
Address:
____________________________________________________ Home Phone: _______________________
Person(s) authorized
to pick up your child: (Besides parents, legal guardians, or emergency
contacts)
Name(s):
_______________________________________________________________________________________
Comments: ______________________________________________________________________________________
_______________________________________________________________________________________________
Kid Code: ________________________________________________ (A secret code
word between parent & child used for identification of any authorized
person when picking up your child. A
driver’s license is also required.)
Child’s
Physician:
_________________________________________________ Phone: ________________________
Child’s
Dentist:
____________________________________________________ Phone:
_________________________
Insurance
Company:
__________________________________________ Policy #:
____________________________
Medical
Conditions:
_______________________________________________________________________________
Regular
Medications:
_____________________________________________________________________________
Medicinal
Allergies:
______________________________________________________________________________
Food Allergies:
__________________________________________________________________________________
Miscellaneous
Allergies:
___________________________________________________________________________
Preferred
Emergency Facility:
Osceola Regional______ Sand Lake Hospital______ Celebration Healthcare______
________________________________________
Mother/Guardian
Signature & Date
___________________________________
Father/Guardian
Signature & Date