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State of Michigan - Department of Licensing and Regulatory Affairs - Child Care 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 field, a line through a field or “N/A” are not acceptable responses.


Parent/Legal Guardian’s

Parent/Legal Guardian’s 1
Parent/Legal Guardian’s 2

Physician or Health Clinic

Emergency Contact & Release of Child: List all individuals, including parents/legal guardians, in order of preference, to be contacted in an emergency. 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.)

Parent/Legal Guardian Initials:

 I give permission to Sunrise Learning Daycare Center licensed by the Department of Licensing and Regulatory Affairs to secure emergency medical treatment for the above named minor child while in care.