Child Information Record
State of Michigan – Department of Licensing and Regulatory Affairs – Child Care Licensing Bureau
Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply,
“unknown” or “none” is the required response. A blank field, a line through a field or “N/A” are not acceptable responses.
On your computer, please download the Child Information form below and then email it to us at [email protected] once it is filled out.
Also a few important tips:
*Please add information for both parent/guardians (if applicable).
*If there are no allergies, please check off the second square on the right that says “no” (_yes x no).
*Emergency Contact & Release of Child: Please specify the relationship to your child. Example: Mandy Smith (Nanny) or Richard Jones (Grandpa) .
*In the section asking about giving Canterbury Creek permission to seek emergency care, please add your initials on the left.
*Please sign and date it at the bottom. Thank you!