CCL-3731 at a glance
What it is: The Child Information Record is a State of Michigan Department of Lifelong Education, Advancement, and Potential - Child Care Licensing form.
Who signs: Sign on the Signature of Parent or Guardian line and enter the Date.
A filled-in CCL-3731 example: a parent fills out the child record
How to fill out CCL-3731, box by box
Name and address of the child
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 field, a strikethrough, or "N/A" are not acceptable responses.
Enter the Name of Child (Last, First, Middle Initial) and the Child's Date of Birth.
Enter the Address (Number and Street, Building/Apartment Number), City, State and Zip Code.
Parent/Legal Guardian
Enter the Parent/Legal Guardian's Name, Primary Phone and 2nd Phone (if applicable).
Enter the Home Address (if not child's address) with City, State and Zip Code, then the Email Address (optional), Employer Name and Work Phone.
Second Parent/Legal Guardian (optional)
A second Parent/Legal Guardian's Name (optional) has the same lines: Primary Phone, 2nd Phone (if applicable), Home Address (if not child's address), City, State, Zip Code, Email Address (optional), Employer Name and Work Phone.
Physician, hospital and allergies
Enter the Name of Child's Physician or Health Clinic and the Physician's or Health Clinic's Phone Number.
Enter the Preferred Hospital for Emergency Treatment (optional) and the Allergies, Disabilities and/or Special Instructions. Attach additional sheets if necessary.
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).
1st Individual and 2nd Individual each have a Phone and a 2nd Phone line.
Release of Child Only
Release of Child Only: List all individuals, other than the parents or legal guardians, to whom the child may be released to (if more individuals, attach additional sheets).
The 1st Individual, 2nd Individual and 3rd Individual in the second list each have a Phone line.
Permission and signature
Parent/Legal Guardian Initials: I, (initial here), give permission to (child care provider), licensed by the Department of Lifelong Education, Advancement, and Potential, to secure emergency medical treatment for the minor child named in Name of Child while in care. By signing you certify that you accurately completed this form and if anything changes, you will notify the provider by updating this form.
Sign on the Signature of Parent or Guardian line and enter the Date.
Sources
[1] Form CCL-3731, Child Information Record, State of Michigan Department of Lifelong Education, Advancement, and Potential (the Official source link on this page).
