Harper Valley Farms - Your Child's Information

At Harper Valley Farms, we believe our children are our biggest asset. They are the seeds we nourish and watch bloom year after year. Their safety is of the utmost importance to us as we are sure it is to you.

Why not print and complete this form? Repeat for each of your children and keep it in a safe place. Provide as much information as you can and include a recent photograph of the child. In the event your child ever goes missing, this will provide Police with vital information about your child to help them in their search. It is also a good idea to provide fingerprints and DNA samples. Call your local Police Department for more information

To print this form, highlight the form from the "start" to the "end" wording. Then select the print button on your browser. If you have MS Word® , you may download a version of this form by clicking here. The file will automatically download to your computer. This way you may print the form annually to update information. You will need Winzip to open the download.

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Place a recent photo
of your child here.

Date of Photo_______________

Child's Full Name______________________________________________
Address_____________________________________________________
City____________________________ State___________ Zip__________
Phone#_____________________ Date of Birth______________________
Nicknames(s)________________________________________________
___________________________________________________________

Medical Conditions:

Allergies__________________________________________
Chronic Illnesses___________________________________
Current Medications_________________________________
__________________________________________________
Doctor__________________________ Phone_____________
Dentist__________________________ Phone_____________

Child lives with: [ ] Mother [ ] Father [ ] Mother & Father [ ] Other

Please complete if child does not live with both parents:

Parent/Guardian_____________________________________
Address___________________________________________
City_________________________ State________ Zip_______
Home Phone______________ Work Phone________________

Other Custodial Adult_________________________________
Address____________________________________________
City________________________ State________ Zip_________
Home Phone_____________ Work Phone__________________

Person with physical custody_____________________________

Complete for Parent/Guardian/Custodial Adult:

Height:___________________ Weight:_______________
Hair Color:________________ Eye Color:_____________
Skin Color:____________ Race:_____________________
Sex_____________ Blood Type_____________________
Shoe Size:________________ Hair Style: ___________________
Scars, birthmarks, or other identifying features (i.e. glasses, braces, pierced ears, etc.)
________________________________________________________
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Social Security Number __________-______-____________
State or Passport Number____________________________

Medical Conditions:

Allergies__________________________________________
Chronic Illnesses___________________________________
Current Medications_________________________________
__________________________________________________
Doctor__________________________ Phone_____________
Dentist__________________________ Phone_____________

Please list known hangouts, relatives, friends, etc.:
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Place your child's hair sample here. Include 25-50 strands with the root attached. Collect them using a clean hairbrush. (Be sure not to taping over the root.) You can also place them in a container with this page.

There are times when a child will simply go to a friend's house without telling you. Other times they may run away or hide out at their favorite place. Use these spaces to fill in some of your child's favorite places or hangouts and the names and addresses of his or her close friends. It is also helpful to write down a few notes as to your child's daily activities on a separate sheet of paper..
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