Child Information Form

  • INSTRUCTIONS TO PARENTS:
    1. Complete all items on this form. Sign and date where indicated.
    2. If your child has a medical condition, which might require emergency medical care, complete the form. If necessary, have your child’s health practitioner review that information.


    NOTE: THIS ENTIRE FORM MUST BE UPDATE ANNUALLY.
  • When parents cannot be reached, list a least one person who may be contacted to pick up the child an emergency / disaster.

  • In EMERGENCIES requiring immediate medical attention, your child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. Your signature authorizes the responsible person at the child care facility to have your child transported to the hospital.
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  • INSTRUCTIONS TO PARENT:
    1. Complete the following items, as appropriate, if your child has a condition(s), which might require emergency medical care.
    2. If necessary, have your child’s health practitioner review the information you provide below and sign and date where indicated.
  • DPTCPVMMRHIB 
  • HEP BVaricellaTB StatusOther 
  • THE FOLLOWING ARE EMERGENCY MEDICAL INSTRUCTIONS FOR A CHILD WITH SPECIAL NEEDS