Get MI BCAL-3731 2012

BCAL-3731 Rev. 7-12 Previous editions 9-09 3-08 10-07 1-06 may be used until 12/31/13. See Reverse Side Emergency Contact Release of Child List all individuals including parents/legal guardians in order of preference to be contacted in an emergency. CHILD INFORMATION RECORD State of Michigan Department of Human Services - Bureau of Children and Adult Licensing 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 eld a line through a eld or N/A are not acceptable responses. For Provider Use Only Date of Admission Date of Discharge Name of Child Last First Middle Initial Child s Date of Birth Address Number and Street Building/Apartment Number City Father/Legal Guardian s Name Home Phone Home Address if not child s address Cell Phone Zip Code State Email Address optional Employer Name Work Phone Name of Child s Physician or Health Clinic Physician s or Health Clinic s Phone Number Hospital Preferred for Emergency Treatment optional Allergies Special Needs and Special Instructions Attach additional sheets if necessary. If possible include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released* The second phone number column can be left blank. If more individuals attach additional sheets. Release of Child Only List all individuals other than the parents/legal guardians to whom the child may be released* If more individuals attach additional sheets. I give permission to licensed by the Department of Human Services Provider s Name to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care. Signature of Parent or Guardian Date Card Reviewed Parent or Legal Guardian Initials Date Signed Department of Human Services DHS will not discriminate against any individual or group because of race religion age national origin color height weight marital status sex sexual orientation gender identity or expression political beliefs or disability. If you need help with reading writing hearing etc* under the Americans with Disabilities Act you are invited to make your needs known to a DHS of ce in your area* AUTHORITY 1973 PA 116 COMPLETION Required PENALTY Rule Violation Citation*. If possible include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released* The second phone number column can be left blank. If more individuals attach additional sheets. Release of Child Only List all individuals other than the parents/legal guardians to whom the child may be released* If more individuals attach additional sheets. If more individuals attach additional sheets. Release of Child Only List all individuals other than the parents/legal guardians to whom the child may be released* If more individuals attach additional sheets. I give permission to licensed by the Department of Human Services Provider s Name to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care. .