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Email Forms Manager

* Indicates required information
Company Name (if subsidizes TLC services): 
Child's Name: * 
Nickname: 
Gender: * 
Date of Birth *    (mm/dd/yyyy)
Child's Physician's Name * 
School/daycare center 
My child likes to talk about: 
Grandparents, pets: 
Siblings and ages: 
My child likes to play with: 
Sleep habits/nap time: 
Food habits/special likes: 
Dislikes: 
Type of formula: 
Warmed? 

Toileting child needs assistance: 

Special methods to comfort my child: 
Child's Health History 
Imunization are on record at: * 
Describe any ongoing health problems: 
Has your child had chickenpox? * 

Medications taken regularly: 
How are medications usually given? 
Hospitalizations with reasons: 
Accidents: 
Allergies: * 
Parent/Guardian Information 
Parent/Guardian name: * 
Social Security Number: 
Work Phone: 
Home Phone: * 
Employer: 
Parent/Guardian 2 name 
Social Security Number: 
Work Phone: 
Home Phone: 
Employer: 
Home Street Address: 
City 
State 
Zip code: 
Emergency Contact Information 
Special directions for contacting parents: 
Alternate contact person: * 
Relationship to child: * 
Phone number: * 
Persons other than parents authorized to pick up child: 
Name: 
Relationship: 
Phone number: 
Name: 
Relationship: 
Phone number: 
Name: 
Relationship: 
Phone number: 
 

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