Child Information Update Print This! Child's Name Date of Birth Male or Female? Male Female Home Address Street City, State & Zip Home Phone Phone Number Parent/Guardian 1 Name Employer Work/Daytime Ph Cell/Other Ph Email Address Work Address Address (if different from child) Rutgers Affiliated Yes No Vehicle Information Make (i.e. Toyota) Model (i.e. Camry) License Plate Parent/Guardian 2 Name Employer Work/Daytime Ph Cell/Other Ph Email Address Work Address Address (if different from child) Rutgers Affiliated Yes No Vehicle Information Make (i.e. Toyota) Model (i.e. Camry) License Plate Persons other than parents/guardians named above who are authorized to pick up your child from R-LDCC, OR whom you authorize the Center to contact, AND who agree to pick up your child in the event that you cannot be reached (illness, emergency, etc.) Name (1) Relationship to Child Home Ph Work/Daytime Ph Cell/Other Ph Address Name (2) Relationship to Child Home Ph Work/Daytime Ph Cell/Other Ph Address Name (3) (optional) Relationship to Child Home Ph Work/Daytime Ph Cell/Other Ph Address Does your child receive any medication at home on a regular basis? Yes No Are there any recent changes or special circumstances of which your child's teachers should be aware? Yes* (if yes, please explain below) No If you answered "yes" above, please explain: A parent/guardian signature below will attest that: (Please read and check BOTH before signing below) My child is in good health and can participate in the normal activities at R-LDCC The information provided here is true to the best of my knowledge. If there are any changes, I will notify R-LDCC in writing. Parent/Guardian Signature signature keyboard Clear Δ