PERSONAL INFORMATIONFULL NAME OF CHILD First Last USUAL NAME OF CHID (if different)DATE OF BIRTHGENDER Male Female ADDRESS Street Address City ZIP / Postal Code MOTHER OR GUARDIAN’S NAME First Last FATHER OR GUARDIAN’S NAME First Last MOTHER OR GUARDIAN’S TELEPHONEFATHER OR GUARDIAN’S TELEPHONEMOTHER OR GUARDIAN’S EMAIL ADDRESS FATHER Or GUARDIAN’S EMAIL ADDRESS EMERGENCY HEALTH INFORMATIONHEALTH CARD NUMBERFAMILY DOCTOR NAMEDOCTOR/ CLINIC ADDRESSDOCTOR/ CLINIC PHONE NUMBERCHILD’S IMMUNIZATION STATUSIS YOUR CHILD UP TO DATE ON IMMUNIZATION? Yes NO NOT IMMUNIZED CONSENT FOR EMERGENCY CAREConsent I authorized the staff at the childcare centre to call a medical practitioner or ambulance/ transport child to emergency medical care, in the case of accident or illness of my child, if the parent cannot immediately be reached.HEALTH INFORMATIONREGULAR MEDICATION(S) AND REASON FOR (please list)ALLERGIES TREATMENT OF (please list)INJURY(S), ILLNESS(ES) OR OPERATIONS YOUR CHILD HAS HAD INCLUDE DATE(S)1. Please describe any concern(s) / issues regarding your child’s health (seizures, asthma, vision, hearing, etc.)2. Please describe any concerns you may have regarding your child’s development (Behaviour, vision, hearing, speech, language, mobility. Etc.)3. Please any specific care instruction regarding.OTHER HEALTH CARE PROFESSIONAL INVOLVED IN YOUR CHILD LIFE (e.g. occupational therapist/ physical therapist)ALTERNATE PERSONS AUTHORIZED TO PICK UP CHILDNameRelationshipAuthorized to PickupAuthorized to Call in an Emergency Add Remove(other than parent/ guardian listed above, include emergency pickup) Check all that applyPERSONS WHO ARE NOT PERMITTED ACCESS TO MY CHILDNameRelationshipTelephone Add RemoveSignaturePrint Name Date
