CHILDCARE FORM

PARENTS/GUARDIANS
Name:_________________________
Name:________________________
Where we/I will be:
_________________________________________________________
Phone number(s) to reach me/us:
_________________________________________________
_________________________________________________
IF YOU CANNOT REACH ME/US
Contact name: _________________________________ Contact phone number: __________________
Contact name: _________________________________ Contact phone number: __________________
Contact name: _________________________________ Contact phone number: __________________
In an emergency we will call 911

HOME INFORMATION
Family Name:
________________________________________________________________________________
Phone:
________________________________________________________________________________
Address:
________________________________________________________________________________
ABOUT THE CHILD(REN)
Name: ____________________________________
Date of Birth:_______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________

Name: ____________________________________
Date of Birth:_______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________
___________________________________________
Name: ____________________________________
Date of Birth:_______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________
___________________________________________
Name: ____________________________________
Date of Birth:_______________________________
Age: ______________________________________
Other Information (allergies, medications, etc.):
___________________________________________
___________________________________________
___________________________________________
OTHER INFORMATION
Bedtime:___________________________________
Extra Notes: ________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Thank You,
Kira & Ally