PORTSMOUTH SCHOOL DEPARTMENT

CHILDCARE PROVIDER INFORMATION

Child’s Name: ________________________________________________________

Will this child be coming to school from a childcare provider? Yes ____ No ____

If yes, please complete the following:

Caregiver’s Name: ____________________________________________

Caregiver’s Address: __________________________________________

Caregiver’s Phone No.: ________________________________________

Will this child be returning from school to a childcare provider? Yes ____ No ____

If yes, and the information is different from above, please complete the following:

Caregiver’s Name: ____________________________________________

Caregiver’s Address: __________________________________________

Caregiver’s Phone No.: ________________________________________

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