FAMILY HEALTH GARDEN
CHILD CARE AUTHORIZATION FORM

Parent/Guardian Information:
- Full Name: ____________________
- Date of Birth: ________________
- Phone Number: ________________
- Email Address: ________________
- Home Address: ________________
- Employment Status: ____________
- Work Schedule: ________________

Child Information:
- Child's Full Name: _____________
- Date of Birth: ________________
- Age: _________________________
- Special Needs/Medical: _________

Child Care Provider:
- Provider Name: ________________
- Provider Address: ______________
- Provider Phone: _______________
- Provider License #: ___________

Type of Care Requested:
□ Full-time care
□ Part-time care
□ Before/After school care
□ Summer care
□ Drop-in care

Schedule Needed:
- Days: _______________________
- Hours: ______________________
- Start Date: __________________

Income Information:
- Monthly Household Income: _____
- Number of Dependents: _________

Reason for Childcare Need:
□ Employment
□ Job training/Education
□ Medical appointments
□ Other: ______________________

Emergency Contacts:
1. Name: ______________________
   Phone: ____________________
   Relationship: ______________

2. Name: ______________________
   Phone: ____________________
   Relationship: ______________

Medical Information:
- Pediatrician: ________________
- Medical Conditions: ___________
- Medications: _________________
- Allergies: ___________________

Authorization:
I authorize FamilyHealthGarden to provide childcare vouchers and support services for the above-named child.

Parent/Guardian Signature: _________________ Date: _______

Submit to: childcare@familyhealthgarden.com