Child Portable Record Information

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Alberta Childcare Licensing mandates the completion of this separate form. This document will accompany the educator during all off-site visits, including nature walks, outdoor play, field trips, or emergency evacuations. (Kindly provide information for all fields; leaving them blank or using ‘ditto’ is unacceptable as it may result in missing data.)

Child’s Information

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Child’s Name

Birth Date

Gender

Male
Female

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Home Address

City

Postal Code

Home Phone

Parent(S)/Guardian Information (#1)

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Parent/Guardian’s Name

Relationship to child

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Home Address

City

Postal Code

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Home #

Work Address

Cell #

Work #

Any Instruction

Parent(S)/Guardian Information (#2)

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Parent/Guardian’s Name

Relationship to child

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Home Address

City

Postal Code

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Home #

Work Address

Cell #

Work #

Any Instruction

Child’s Physician or Healthcare Professional

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Physician’s Name

Address

Telephone

Child’s AHC #

Information on allergies, special diets, chronic health conditions, special limitations, concerns, including medications the child is taking at home/ school and possible side effects:*

Information on allergies

Child’s immunization complete?*

Emergency Contact Information

Emergency contact for parent/ guardian (#1)

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Name

Relationship to the child

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Address

Home / Work #

Cell #

Emergency contact for parent/ guardian (#2)

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Name

Relationship to the child

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Address

Home / Work #

Cell #