Infant Care Information Sheet

INFANT CARE INFORMATION SHEET

The undersigned parent or legal guardian provides the following information and authorizations to assist the caregiver in providing safe, appropriate, and individualized care for the named infant. The information provided is true and complete to the best of the undersigned's knowledge. The caregiver is authorized to follow the instructions below and to act on behalf of the undersigned as expressly permitted herein in the event of an emergency.

Child Information

Child Full Name:

Date of Birth:     Gender:     Preferred Name/Nickname:

Parent / Legal Guardian

Emergency Contacts (Other than Parent)

Relationship:     Phone:

Relationship:     Phone:

Medical & Health Information

Authorization to administer medication as directed below: Yes     No

Immunizations up to date: Yes     No     Date of last immunization:

Feeding & Daily Care

Formula or Breastmilk Details:     Solids introduced:

Sleeping & Safety

Typical Nap Schedule:

Preferred Sleep Position: Back (recommended)    Side    Stomach

Diapering & Hygiene

Consent to use diaper cream / sunscreen: Yes    No     If yes, brand/name:

Authorized Pickup

List persons authorized to pick up the child. Caregiver may require photo identification.

Relationship:     Phone:     Require ID:

Relationship:     Phone:     Require ID:

Relationship:     Phone:     Require ID:

Consent & Legal Acknowledgements

Authorization for Emergency Medical Treatment: In the event of sudden illness or injury, and if the parent/legal guardian cannot be reached after reasonable effort, I authorize the caregiver to seek emergency medical care and to consent to medical treatment as necessary for the health and safety of my child, including transportation to an emergency facility. I understand that reasonable attempts will be made to contact me prior to such action whenever practicable.

Confidentiality: The caregiver will maintain the privacy of the child's personal and health information and will disclose such information only as necessary for care, to medical personnel in an emergency, or as required by law.

Liability and Release: The undersigned acknowledges that childcare activities carry inherent risks. To the fullest extent permitted by law, the undersigned releases and agrees to indemnify the caregiver and its employees from any claim, liability, loss, or expense arising from ordinary negligence in providing routine infant care, except for acts of gross negligence or willful misconduct.

Transportation / Field Trip Consent: I authorize the caregiver to transport my child for local outings or emergency transport as described above: Yes    No

Photo and Video Release: I consent to the use of photographs or video of my child for program documentation and internal communications: Yes    No

Accuracy Certification: I certify that the information provided on this form is complete and accurate. I will notify the caregiver immediately of any changes to the child's health, medications, authorized pickup persons, or emergency contacts.

Additional Instructions / Notes

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