Just print out these information cards, fill them out then bring them into your nearest location. Don't forget about the coupon on the bottom of this page.
CHILD INFORMATION CARD Michigan Department of Social Services
| Name of child (Last, First, Middle Initial) | Name of Both Parents or Guardian | |||
| Allergies, If Any | Address (Number and Street) | |||
| Child's Date of Birth | Home Phone Number | City | State | Zip Code |
| 1. Parent's Work (Company Name) if blank same as home address | Work Phone | |||
| Address (Number and Street) | City | State | Zip Code | |
| 2. Parent's Work (Company Name) | Work Phone | |||
| Address (Number and Street) | City | State | Zip Code | |
PERSONS OTHER THAN PARENT TO BE NOTIFIED IN EMERGENCY SITUATION OR TO BE RELEASE TO WHEN PARENT IS NOT AVAILABLE
| Name | Phone Number | ||
| Address (Number and Street) | City | State | Zip Code |
NAMES OF PERSONS OTHER THAN PARENT TO WHOME CHILD MAY BE RELEASED & PHONE NUMBER
| 1 | 3 |
| 2 | 4 |
| I
Hereby give permission to MY PLACE JUST FOR KIDS
Licensed by the Department of Social Services to secure
emergency medical care and/or emergency surgical
treatment for the above named minor child while in care. Non-medical treatment or elective surgery is not included in the authorization. |
|
| Signature of Parent or Guardian | Date Signed |
(Space for Notarization, if Required by Rule)
| Name of Child's Physician or Health Clinic | Office Hours | Phone Number | |
| Address (Number and Street) | City | State | Zip Code |
| Hospital
Preferred for Emergency Treatment Nearest or: |
Health Insurance Identification Information | ||
The Department of Social Services will not discriminate against any Individual or group because of race, sex, religion, age, national origin, color, marital status, handicap, or political beliefs.
