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.

ClassesSummer Camp

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 things to help us out:

*Please add information for both parent/guardians if there are more than one (even though it says optional)

*If there are no allergies, please check off the second square on the right that says “no” (yes _ no x)

*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!