Child Dossier Please complete all areas of the dossier. Name of Child * Date of Birth * MM DD YYYY Mother or guardian's name * Calling Order * 1 2 Address * Cell * (###) ### #### Home (###) ### #### Work (###) ### #### Email * Father or guardian's name * Calling Order * 1 2 Address * If same as the mother's address, write same address Cell * (###) ### #### Home (###) ### #### Work (###) ### #### Email * Child lives with... * Comments Sibling 1 - Name Sibling 1 - Date of Birth MM DD YYYY Sibling 2 - Name Sibling 2 - Date of Birth MM DD YYYY Sibling 3 - Name Sibling 3 - Date of Birth MM DD YYYY Languages Spoke * Do you self identify as aboriginal? * Yes No Medical Information Care Card Number * Doctor's name * Doctor's Phone Number * (###) ### #### Dentist * Dentist Phone Number * (###) ### #### Vaccinations up to date Yes No Allergies Please list any MedicAlert Bracelet * Yes No Medications Specific diet and dietary restriction Child’s illnesses, diagnosis, or particular conditions of: please specify In case of emergency, after the parents, please contact: Emergency Contact 1 - Name * Emergency Contact 1 - Cell (###) ### #### Emergency Contact 1 - Home (###) ### #### Emergency Contact 2 - Name Emergency Contact 1 - Cell (###) ### #### Emergency Contact 2 - Home (###) ### #### The only people allowed (other than previously named) to pick my child up are: Pick Up Contact 1 - Name Pick Up Contact 1 - Cell (###) ### #### Pick Up Contact 1 - Home (###) ### #### Pick Up Contact 2 - Name Pick Up Contact 2 - Cell (###) ### #### Pick Up Contact 2 - Home (###) ### #### The following people are not permitted access to my child (please email us a photo): Name 1 - No access to child Name 2 - No access to child Name 3 - No access to child By typing your name you attest to this information being correct. Parent/Guardian * First Name Last Name Thank you for filling out the Child Dossier.
