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Get MI BCAL-3731 2009

Date of Admission Allergies child information record state of michigan Department of Human Services Bureau of Children and Adult Licensing Date of Discharge Name of Child Last First Middle Initial Child s Date of Birth Address Number and Street Building/Apartment Number Home Phone City State Zip Code Father/Legal Guardian s Name Home Address if not child s address Cell Phone Employer/School Name Address Employer/School Daily Work/School Times Name s of Person other than Parent or Legal Guardian to whom child may be released See Reverse Side BCAL-3731 Rev. 9-09 Previous editions 3-08 10-07 1-06 may be used. 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 Signed Name of Child s Physician or Health Clinic Physician s or Health Clinic s Phone Number Address of Child s Physician or Health Clinic Name of Health Insurance Carrier Hospital Preferred for Emergency Treatment Health Insurance Policy Number Special Needs Date of Last DTaP Diptheria tetanus pertussis Shot Name of Local Person to be Notified in an Emergency When Parents Not Available Local Address of Emergency Person Home and/or Cell Phone City State Work Number Special Instructions 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 office in your area* AUTHORITY 1973 PA 116 COMPLETION Required PENALTY Rule Violation Citation*. Signature of Parent or Guardian Date Signed Name of Child s Physician or Health Clinic Physician s or Health Clinic s Phone Number Address of Child s Physician or Health Clinic Name of Health Insurance Carrier Hospital Preferred for Emergency Treatment Health Insurance Policy Number Special Needs Date of Last DTaP Diptheria tetanus pertussis Shot Name of Local Person to be Notified in an Emergency When Parents Not Available Local Address of Emergency Person Home and/or Cell Phone City State Work Number Special Instructions 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 office in your area* AUTHORITY 1973 PA 116 COMPLETION Required PENALTY Rule Violation Citation*. .

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