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Child Reunification Considerations for Communities

12. Appendices

12.12. Appendix L: Child Intake Form

To collect identifying information for unaccompanied minors during registration at the Family Reunification Center.

Child Information
Name (Last, First, Middle): DOB/Age: _____________ ☐ Unknown
Eye Color: ☐ Brown ☐ Blue ☐ Green ☐ Hazel
☐ Other		 Hair Color: ☐ Brown ☐ Blonde ☐ Black
☐ Red ☐ Other
Primary Language: ☐ English ☐ Spanish ☐ Other: ________________________ ☐ Non-verbal
Identifying Features:

☐ Scars
☐ Moles
☐ Birthmarks
☐ Tattoos
☐ Braces
☐ Missing Teeth
☐ Glasses
☐ Other:		 Items worn by or with child when found:

☐ Pants/Shorts
☐ Shirt
☐ Dress/Skirt
☐ Shoes/Socks
☐ Coat/Jacket
☐ Jewelry
☐ Medical Devices
☐ Other:		 Photo







Attach a photo here
Describe all checked items:
Describe where the child was found (Be as specific as possible, including neighborhood/street names):
Arrival to Family Reunification Center
Method: ☐ Private Vehicle ☐ EMS ☐ Public Transport ☐ Other:
Details of Arrival:
Wristband Placed on Child:
☐ Yes ☐ No		 Staff Responsible for Registration (Print Name):
Additional Information
Parent/Guardian Name: Parent/Guardian Contact Number:
Parent/Guardian Location Known?
☐ Yes ☐ No

Current Location:		 Additional Family Member Names, Age, Location, & Contact Number?

☐ Sibling(s) ☐ Grandparent ☐ Aunt/Uncle ☐ Cousin ☐ Other____
Pet Name(s):
☐ Dog ☐ Cat ☐ Other___________
Name of School: Grade: Teacher(s) Name:
Disposition
☐ Child Transferred to another facility/agency (Facility Name):

Address: ______________________________________________ Phone: ______________________

Contact: ______________________________________________ Transport Agency: ______________________
Parent/Guardian Contacted? ☐ Yes ☐ No

Contacted By:

Date/Time:
☐ Child Released to (Full Name): ______________________________________________ Known to Child? ☐ Yes ☐ No

Relationship to Patient: ☐ Parent/Guardian ☐ Sibling ☐ Aunt/Uncle/Cousin ☐ Grandparent ☐ Other: __________

Picture Identification: ☐ Driver’s License ☐ Passport ☐ Work/School ID ☐ Other: ______________________

Address on ID: ______________________________________________ Consent obtained from parent/guardian if released to another adult? ☐ Yes ☐ No (explain):
☐ Signature of Individual Assuming Responsibility for Child (Sign, Date, Time):

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