Sts. Peter and Paul
C.A.R.E.S. Program
FAMILY INFORMATION
Child’s Name: _____________________________ Birth Date: _____________________
Child’s Name: _____________________________ Birth Date: _____________________
Home Phone: ______________________________
Address: ______________________________
_______________________________
Mother’s Name:______________________________________ Home Phone: _______________________________
Work Phone: _______________________________
Father’s Name: ______________________________________ Home Phone: _______________________________
Work Phone: _______________________________
EMERGENCY CONTACT PERSON
1. Name ___________________________________ Home Phone ____________________________________
Work Phone: ____________________________________
Relationship: ___________________________________
2. Name: ____________________________________ Home Phone: ____________________________________
Work Phone ____________________________________
Relationship ____________________________________
MEDICAL INFORMATION
Child’s Doctor: __________________________________________________
Name of Practice: _________________________________________________
Address __________________________________________________
Phone ___________________________________________________
Health Coverage Source: ____________________________________________ Policy #: _______________________________
Does your child have any food or drug allergies? If so, please list:
_________________________________________________________________________________
_________________________________________________________________________________
IF THERE IS A MEDICAL EMERGENCY AND NONE OF THE ABOVE CAN BE REACHED, I WANT MY CHILD TAKEN TO THE EMERGENCY ROOM: YES NO (PLEASE CIRCLE)
I WANT MY CHILD'S DOCTOR NOTIFIED: YES NO (PLEASE CIRCLE)