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    SFN 00845

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    HANALLY JOYCE AROMIN

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    © All Rights Reserved
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    SFN 00845

    Uploaded by

    HANALLY JOYCE AROMIN
    6 views1 page

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    sfn00845

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    Copyright:

    © All Rights Reserved
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    6 views1 page

    SFN 00845

    Uploaded by

    HANALLY JOYCE AROMIN

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    CHILD INFORMATION SHEET

    NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES Clear Fields


    EARLY CHILDHOOD DIVISION
    SFN 845 (5-2022)

    Every Early Childhood Program is required to have certain information on file. These requirements are set forth in the rules
    and regulations for Early Childhood Services as adopted by the North Dakota Department of Human Services. All information
    requested herein is required and shall be kept confidential.
    Child's Name Date Child Enrolled Preferred or Nickname of Child Date of Birth

    Parent's Name Home Telephone Number Cell Phone Number Work Telephone Number

    Home Address Place of Employment

    Parent's Name Home Telephone Number Cell Phone Number Work Telephone Number

    Home Address Place of Employment

    EMERGENCY AUTHORIZATION
    In case of an emergency and parents cannot be reached, who should be contacted?
    Name Relationship to Child Work Telephone Number Home Telephone Number

    Name Relationship to Child Work Telephone Number Home Telephone Number

    Physician to Call in an Emergency Clinic Telephone Number

    Dentist to Call in an Emergency Clinic Telephone Number

    I hereby authorize the Early Childhood Program to secure emergency medical treatment for my child under the following conditions:
    1. An emergency or unanticipated condition necessitates immediate action for the preservation of the life or health of the child, and
    2. Reasonable attempts to contact me have failed.
    Parent Signature Date Parent Signature Date

    AUTHORIZATION TO RELEASE CHILD


    Unless otherwise authorized by you in writing, only the parent or legal guardian may pick up your child(ren) from the Early Childhood
    Program. List below any others you wish to authorize for this purpose.
    Name Relationship to Child Telephone Number

    Name Relationship to Child Telephone Number

    Name Relationship to Child Telephone Number

    These people are NOT allowed to pick up my child.


    Name Relationship to Child

    Name Relationship to Child

    For Operator Use Only:

    Per North Dakota Century Code section 12-60-26(7)(c), proof of identity means a certified copy of a birth certificate or any other documentary
    evidence the child care facility considers appropriate proof of identity.
    The identification of this child has been verified. As proof of identification, the child's parent has produced:
    Copy of Child's Birth Certificate Child's Passport Other
    Signature of Operator

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