Tide Pool Adventure at local beach – Woodland Place Child Care Center

Child Information

Child’s Name:

Date of Birth:

Age at Admission:

Date of Admission:

Child’s Home Address:

Home Phone Number:

Primary Language:

Identifying Marks:

Eye Color:

Hair Color:

Skin Color:

Sex:

Height:

Weight:

Parent/Guardian Information

Parent/Guardian Name:

Relationship to Child:

Home Address:

Reachable Phone Number:

Email Address:

Business Name:

Business Address:

Business Phone Number:

Hours at Work:

Additional Information

Child’s Physician:

Address:

Phone Number:

Allergies/ Special Diets? :

Individual Health Plan for child with chronic health conditions? If yes, please attach.

Copies of any custody agreements, court orders, and restraining orders pertaining to the child?

Special limitations or concerns?

School Age Only

Current School:

School Address:

School Phone Number:

certify that documentation of physical examination and immunizations in accordance with public
school health requirements and lead poisoning screening in accordance with public health require-
ments are on file at my child’s school.
Parent/ Guardian Initials:

Parent/Guardian Signature

Date