Half Dozen & One

Megan's country Childcare

Child Enrollment & Health Records

Please complete one form for each child. Fields marked * are required. This information helps us contact your family and care for your child. For urgent medical concerns or changes in care, please speak with Megan directly. Do not use this form for an emergency.

1. Emergency Information & Family Contacts

Parent/guardian contact information, work locations, and primary physician.

Child's full name *

Date of birth *

Parent/guardian name(s) *

Home address *

Primary phone *

Secondary phone

Parent/guardian email *

Work location(s)

Primary physician name

Physician phone

Preferred hospital, if needed

2. Medical & Allergy History

Share relevant health information and dietary needs. Provide immunization documentation separately as requested by the childcare provider.

Known allergies (food, medication, environmental) *

Dietary restrictions

Chronic health conditions

Other medical information we should know

Immunization record status

3. Emergency Medical Authorization

Please review the authorization and sign below.

I authorize emergency medical treatment as stated above. *

Parent/guardian printed name *

Date *

Electronic signature (type your full name) *Typing your name records your acknowledgment. Additional ink signatures may still be required on state licensing forms.

4. Authorized Pickup List

People approved to pick up your child. Staff will verify identity as necessary.

Authorized person 1

Name

Relationship

Phone number

Authorized person 2

Name

Relationship

Phone number

Authorized person 3

Name

Relationship

Phone number

5. Permissions & Releases

Make a separate choice for each permission. No permission is assumed.

Photo release: I permit photos of my child for classroom use. *

Field trips: I permit my child to participate in supervised field trips. *

Sunscreen: I permit staff to apply sunscreen to my child as needed. *

Specialized care (if applicable, e.g. nebulizer care, LIC 9166)

Specialized care details (if applicable)This form does not authorize administration of medication or specialized treatment. Complete any required separate forms.

Parent/guardian printed name *

Date *

Electronic signature (type your full name) *

Your submission contains private information about a child. Please use a private connection and avoid submitting from a shared device. Submission is sent directly to the daycare's designated email through the configured form service. This is an intake supplement and may not replace California child care licensing documents.