Form BCAL-3731 PDF Details

Ensuring the safety and well-being of children in care facilities or under the supervision of any child care provider is a paramount concern for both parents and regulatory agencies. The State of Michigan Department of Human Services - Bureau of Children and Adult Licensing steps in to aid this effort through the BCAL-3731 form, known as the Child Information Record. This form serves as a comprehensive repository of vital details about a child, encompassing personal information, parental or legal guardian contact details, medical information, and emergency contact preferences. Each section of the form must be filled out meticulously, leaving no field blank; for non-applicable fields, responses such as 'unknown' or 'none' are acceptable while leaving a field blank or marking it 'N/A' is not. This stringent requirement ensures that child care providers have immediate access to critical information, should an emergency arise. Additionally, the form includes a section for listing individuals authorized by the parent or guardian to pick up the child, reinforcing the child's security. The BCAL-3731 form also manifests the legal framework surrounding child care in Michigan, highlighting mandatory completion to comply with Public Act 116 of 1973, while underscoring the commitment of the Department of Human Services not to discriminate on various grounds. Integral to the child care process, this document empowers providers to secure emergency medical treatment if necessary, thereby playing a crucial role in safeguarding children under their watch.

QuestionAnswer
Form Name Form Bcal 3731
Form Length 1 pages
Fillable? Yes
Fillable fields 77
Avg. time to fill out 15 min 39 sec
Other names bcal 3731, state of michigan child information record, bcal 3731 form, bcal3731

Form Preview Example

CHILD INFORMATION RECORD

State of Michigan Department of Human Services - Bureau of Children and Adult Licensing

Instructions: Unless otherwise indicated, all requested information must be provided. If the information is not known or does not apply, “unknown” or “none” is the required response. A blank fi eld, a line through a fi eld or “N/A” are not acceptable responses.

For Provider

Date of Admission

 

Date of Discharge

 

 

 

 

 

 

Use Only:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Child (Last, First, Middle Initial)

 

 

 

 

 

 

Child’s Date of Birth

 

 

 

 

 

 

 

 

Address (Number and Street, Building/Apartment Number)

City

 

 

State

Zip Code

 

 

 

 

 

 

 

Father/Legal Guardian’s Name

Home Phone

Mother/Legal Guardian’s Name

Home Phone

 

 

 

(

)

 

 

 

 

(

)

 

 

 

 

 

Home Address (if not child’s address)

Cell Phone

Home Address (if not child’s address)

Cell Phone

 

 

 

(

)

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

Email Address (optional)

 

 

Email Address (optional)

 

 

 

 

 

 

 

 

 

Employer Name

 

 

Work Phone

Employer Name

Work Phone

 

 

 

(

)

 

 

 

 

(

)

 

 

 

 

 

 

 

Name of Child’s Physician or Health Clinic

 

 

Physician’s or Health Clinic’s Phone Number

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital Preferred for Emergency Treatment (optional)

Allergies, Special Needs and Special Instructions (Attach additional sheets, if necessary.)

BCAL-3731 (Rev. 7-12) Previous editions 9-09, 3-08, 10-07, & 1-06 may be used until 12/31/13.

See Reverse Side

Emergency Contact & Release of Child: List all individuals,including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank. (If more individuals, attach additional sheets.)

1.

()

()

2.

()

()

3.

()

()

Release of Child Only: List all individuals, other than the parents/legal guardians, to whom the child may be released. (If more individuals, attach additional sheets.)

1.

3.

(

)

2.

(

)

(

)

4.

(

)

 

 

 

 

 

I give permission to

, licensed by the Department of Human Services

(Provider’s Name)

to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care.

Signature of Parent or Guardian

Date Signed

 

 

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

Date Card Reviewed

Parent or Legal Guardian Initials

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS offi ce in your area.

AUTHORITY: 1973 PA 116

COMPLETION: Required

PENALTY: Rule Violation Citation.

BCAL-3731 (Rev. 7-12) Previous editions 9-09,3-08, 10-07, & 1-06 may be used until 12/31/13.

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