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Sample Children'S Data Form: Page 1 of 3

This 3 page document contains a child's personal information including name, address, parents' contact details, emergency contacts, medical information, and notes on any special needs or preexisting conditions. Key details include the child's name, date of birth, home address, parents' names and contact numbers, who the child lives with primarily, who is the legal guardian, and alternate contacts authorized to pick up the child. It also lists the child's doctor or clinic, any medications, special needs, allergies or health concerns.

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919 views2 pages

Sample Children'S Data Form: Page 1 of 3

This 3 page document contains a child's personal information including name, address, parents' contact details, emergency contacts, medical information, and notes on any special needs or preexisting conditions. Key details include the child's name, date of birth, home address, parents' names and contact numbers, who the child lives with primarily, who is the legal guardian, and alternate contacts authorized to pick up the child. It also lists the child's doctor or clinic, any medications, special needs, allergies or health concerns.

Uploaded by

api-375545407
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SAMPLE CHILDREN’S DATA FORM Page 1 of 3

Child’s Name Sex Age Date of birth

Home Address (Street)

City______________________________________________________________________________________

Home Phone Number: _______________________________________________

Father’s Name:______________________________________________________

Phone Number: _____________________________________________________

Father’s Home Address (if different from child’s) Street

City:____________________________________________________

Father’s Place of Employment:____________________________ Work Phone

Mother’s Name Phone Number

Mother’s Place of Employment Work


Phone:__________________________

Child’s Living Arrangements: (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other

Child’s Legal Guardian(s): (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other

The child may be released to the person(s) signing this agreement or to the following:

*Name Address

Telephone Number
Relationship to child
Relationship to Parent(s) or Guardian
Other identifying information (if any)

*Name Address
(Street-City-State-Zip)
Telephone Number
Relationship to child
Relationship to Parent(s) or Guardian
Other identifying information (if any)
PAGE 2 of 3

Persons to contact in the case of emergency when parent or guardian cannot be reached:

Name Telephone Number

Name Telephone Number

Name Telephone Number

Name of Public or Private School child attends, if any:

Child’s doctor or clinic name

Doctor/clinic phone #

My child has the following special needs

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following
preexisting illness, allergies, or health concerns:

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