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INFORMATION ABOUT THE CHILD
Name : ...............................................First Name : .........................................................
Date and place of birth : ..........................................................
Vaccination's dates (BCG and Pentacoq obligatory) :
...............................................................................................................................
Health problem to signal :
...............................................................................................................................
...............................................................................................................................
Address :
...............................................................................................................................
Holiday address :
...............................................................................................................................
Holiday phone number : ......................................................
INFORMATION ABOUT THE PARENTS
Father's Name and First Name.................................................................................
Mother's Name and First Name : .............................................................................
Person to contact in case of emergency :..................................................................
Phone number.........................................................................................................
Person authorised to take the child:
Name : ....................................................First Name
: ..........................................
AUTHORISATION
I undersigned M. ……………………………………,
father, mother,
guardian, (circle as appropriate).
Other (precise) …………………………………………………………………
Of the child ………………………………………………
1. Attest to know the interior settlement of The Chavants Day Nursery
and approve it.
2. Authorise, in case of accident or illness, The Chavants Day Nursery,
to take the above named child to hospital, and to allow all urgent treatment
to be given in accordance with his/her state.
3. State on one's honour that these information are right.
Les Houches: ………
Firm (read and approved):
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