New York Life Child Id & Safety Program (Child'S Information Page)
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1New York Life Child ID & Safety Program
Child’s Information Page
Child’s photo, fingerprints, and information are deleted upon creation of ID; no child’s
information is kept!
Child’s First Name:
Middle Name:
Last Name:
Nickname:
Gender:
Height:
Weight (lbs):
Eye Color:
qMale qFemale
Hair Color:
Glasses:
Race for Identification:
Birth Month:
Day:
Year:
Other Notes and Health Considerations:
Distinguishing Marks:
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Parent / Guardian Name(s):
Parent / Guardian Name(s):
Street Address, City, State, Zip:
Street Address, City, State, Zip
First Phone Number
Secondary Phone Number:
(
)
(
)
Email Address:
Most families have questions about one or more of the following topics. As a resource to the community, New
York Life can provide you with information to learn more about (check all that apply):
q College Funding
q Rollover of old 401k or IRA
q Life insurance
q Retirement Planning
q Mortgage Protection
q Disability Insurance
q Long Term Care Insurance
q Supplemental Retirement Income
I the undersigned_______________________, am the parent/guardian of minor____________________,
and have full authority to authorize New York Life to create a child identification CD for my child.
Signature _____________________________
Parent/Guardian Signature
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