Form CFS 428 Application/Record of Child Information - Illinois

Form CFS428 or the "Application/record Of Child Information" is a form issued by the Illinois Department of Children and Family Services.

Download a PDF version of the Form CFS428 down below or find it on the Illinois Department of Children and Family Services Forms website.

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State of Illinois
CFS 428
Department of Children and Family Services
Rev. 4/2001
APPLICATION/RECORD OF CHILD INFORMATION
Name of Child
Birthdate
Sex
Address
Date Child Received
Date Child Left
PARENT OR OTHER PERSONS(S) PLACING THE CHILD
Name
Name
Relation to child
Relation to child
Home address
Home address
Phone Number
Phone Number
Place of employment
Place of employment
Address
Address
Phone Number
Phone Number
Working hours
Working hours
OTHER PERSON TO NOTIFY IF PERSON PLACING THE CHILD CANNOT BE REACHED
Name
Address
Phone Number
Relationship
PHYSICIAN TO CALL IF CHILD BECOMES ILL OR INJURED
Name
Address
Phone Number
Hospital or Clinic
PROGRAM
Days per week
Hours of care
Rate of pay (optional)
Signature of parent or other person placing child
Signature of caregiver
Date
A completely filled in form must be kept by the licensee for each child not related to the licensee. Please have this form available at all
times to licensing representatives of the Department of Children and Family Services. Contact the Area Office for supplies of this form.
State of Illinois
CFS 428
Department of Children and Family Services
Rev. 4/2001
APPLICATION/RECORD OF CHILD INFORMATION
Name of Child
Birthdate
Sex
Address
Date Child Received
Date Child Left
PARENT OR OTHER PERSONS(S) PLACING THE CHILD
Name
Name
Relation to child
Relation to child
Home address
Home address
Phone Number
Phone Number
Place of employment
Place of employment
Address
Address
Phone Number
Phone Number
Working hours
Working hours
OTHER PERSON TO NOTIFY IF PERSON PLACING THE CHILD CANNOT BE REACHED
Name
Address
Phone Number
Relationship
PHYSICIAN TO CALL IF CHILD BECOMES ILL OR INJURED
Name
Address
Phone Number
Hospital or Clinic
PROGRAM
Days per week
Hours of care
Rate of pay (optional)
Signature of parent or other person placing child
Signature of caregiver
Date
A completely filled in form must be kept by the licensee for each child not related to the licensee. Please have this form available at all
times to licensing representatives of the Department of Children and Family Services. Contact the Area Office for supplies of this form.
If the child has any of the following, please explaining:
Medical problems
Physical handicaps
Restrictions for play—outdoors
Restrictions for play—indoors
Allergies
Food likes
Food dislikes
Fears
Does the child take a nap?
Time
Length
Is the child toilet trained?
Does the child have special names for objects? (potty, cookies, drinks, etc.)
Does the child regularly take medication?
If so, what kind and directions
If the child is an infant, what are the feeding instructions?
Time
Amount
Temperature
Diaper changes:
Powder
Ointment
Other information that will help in caring for the child
Comments:
ALL INFORMATION SHALL BE REGARDED AND HANDLED CONFIDENTIALLY

Download Form CFS 428 Application/Record of Child Information - Illinois

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