Bcal 3731
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ChristianChildCareBcal 3731
Uploaded by
ChristianChildCareDate of Admission Allergies
child information record
state of michigan
Date of Discharge Department of Human Services
Bureau of Children and Adult Licensing
Name of Child (Last, First, Middle Initial) Address (Number and Street, Building/Apartment Number)
Child’s Date of Birth Home Phone City State Zip Code
( )
Father/Legal Guardian’s Name Home Phone Mother/Legal Guardian’s Name Home Phone
Home Address (if not child’s address) Cell Phone Home Address (if not child’s address) Cell Phone
City State Zip Code City State Zip Code
Employer/School Name Employer/School Name
Address (Employer/School) Address (Employer/School)
City State Zip Code City State Zip Code
Employer/School Phone Daily Work/School Times Employer/School Phone Daily Work/School Times
( )
Name(s) of Person other than Parent or Legal Guardian to whom child may be released
BCAL-3731 (Rev. 9-09) Previous editions 3-08, 10-07, & 1-06 may be used. See Reverse Side
I give permission to , licensed by the Department of Human Services
(Provider’s Name)
to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care.
Signature of Parent or Guardian Date Signed
Name of Child’s Physician or Health Clinic Physician’s or Health Clinic’s Phone Number
( )
Address of Child’s Physician or Health Clinic Name of Health Insurance Carrier
Hospital Preferred for Emergency Treatment Health Insurance Policy Number
Special Needs: Date of Last DTaP (Diptheria, tetanus, pertussis) Shot
Name of Local Person to be Notified in an Emergency When Parents Not Available Local Address of Emergency Person
Home and/or Cell Phone Work Number City, State Zip code
( ) ( )
Special Instructions:
Department of Human Services (DHS) will not discriminate against any individual or group because of race, AUTHORITY: 1973 PA 116
religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or
expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans COMPLETION: Required
with Disabilities Act, you are invited to make your needs known to a DHS office in your area. PENALTY: Rule Violation Citation.
BCAL-3731 (Rev. 9-09) Previous editions 3-08, 10-07, & 1-06 may be used.