State Department of Education To be completed by parent or guardian and
Child Development Division updated at recertification and as changes occurs.
CD-9607 (Rev 09/05)
Child’s name (Last, First, Middle): Birth Date:
Child’s Address: Phone:
Mother’s business address: Phone:
Father’s business address: Phone:
Name Telephone Relationship
Name Address Telephone Relationship
In case of an accident or an emergency, I authorize a staff member of the child development agency to take my child to the above-named physician or to the nearest emergency hospital for such emergency treatment and measures as are deemed necessary for the safety and protection of the child, at my expense.
Parent or Guardian