Child Record Form

This document is a child record form to be completed by a parent or guardian for a childminder. It collects contact information for the child's parents and emergency contacts. It also requests details about the child's health, including immunizations, medical conditions, diet, and development. Space is provided for noting the child's preferences, cultural background, and anything else important for the childminder to know. The parent must sign and date the completed form.

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Child Record Form

Uploaded by

api-344101976

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

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CHILD RECORD FORM

To be completed and signed by the parent/guardian/carer and given to the childminder.

Childs name _______ Date of birth

Home address ___________________________________________________________________________
_________________________________________________ Telephone number _____________________
Parent/Guardian/Carers Name____________________________________________________________
Address (if different from above) ___________________________________________________________
Place of work ____________________Work number ___________________Mobile _________________
Parent/Guardian/Carers Name____________________________________________________________
Address (if different from above) ___________________________________________________________
Place of work ____________________Work number ___________________Mobile _________________
Who to contact in an emergency (other than Parent/guardian/carer) ____________________________
________________________________________________ Telephone number ______________________
Name of person who will collect child_______________________________________________________
Other persons who may collect child ________________________________________________________
Further information (if necessary) _________________________________________________________
Childs doctor______________________________________ Address _____________________________
_________________________________________________Telephone number _____________________
Immunisation/Vaccinations: Has the child been fully immunised against:
Diphtheria
Whooping cough
Tetanus
Polio
Measles
Mumps
Rubella
Hib Meningitis
Other________________________________________________________________
Health clinic___________________________________Health visitor______________________________
Special Diet/ Allergies/ Health problems/ Childhood illnesses____________________________________
_______________________________________________________________________________________

Language spoken at home ___ Childs religion/culture _

Anything else the childminder should know about your child e.g. likes, dislikes, fears, comfort items,
special words ___________________________________________________________________________
_______________________________________________________________________________________
PARENT/GUARDIAN/CARER Signature _____________________________ Date ________________

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Child Record Form

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Child Record Form

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CHILD RECORD FORM

To be completed and signed by the parent/guardian/carer and given to the childminder.

Childs name ___________________________________ Date of birth____________________________

Language spoken at home _______________________ Childs religion/culture _____________________

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Childs name _______ Date of birth

Language spoken at home ___ Childs religion/culture _