Intake Information - Gilmore City

Child's Name

First Last

Child's Date of Birth

Child's Address

Street Address Address Line 2 City State ZIP Code

Does the child reside with one or both parents?

Mother Only

Father Only

Both Parents

Mother's Name

First Last

Mother's Address

Street Address Address Line 2 City State ZIP Code

Mother's Home Phone

Mother's Cell or Work Phone

Mother's Email

Father's Name

First Last

Father's Address

Street Address Address Line 2 City State ZIP Code

Father's Home Phone

Father's Cell or Work Phone

Father's Email

Child's Doctor

Doctor's Phone

Preferred Hospital

Medical Insurance Carrier

Policy #

Child's Dentist

Dentist's Phone

Dental Insurance Carrier

Policy #

In case one or both parents cannot be reached

List

Name

Relationship

Home Phone

Cell or Work Phone

Select the plus sign on the right to add additional contacts.

Signature

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Gilmore City – Bradgate CSD