Child'S Emergency Information

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Child's Emergency Information
(Required Form)
Child Care Regulation 31 requires every licensee to maintain a portable
Date:
/
/
record of emergency information for each child attending the facility.
Year
Month
Day
Child's name:
Personal Health Number :
_____
Date of Birth:
/
/
Group Medical Services or
Year
Month
Day
Medical Services Incorporated Number:
_____
Mother's name:
Father’s name:
____
Address:
Address:
_____
Postal Code:
Postal Code:
_____
Home phone:
Home phone:
____
Business phone:
Business phone: _____________________________________________
Cell phone: ___________________________________________________
Cell phone: _________________________________________________
Two other persons to contact in case of emergency:
2
2. Name: ________________________________________________
1.
Name:
_
Relationship: ____________________________________________
Relationship:
__________
Home phone: ____________________________________________
Home phone:
______
Business phone: __________________________________________
Business phone: ______________________________________________
Cell phone: ______________________________________________
Cell phone:
Physician’s name: ___________________________________________________________________ Phone: ___________________________________
Address:
___
(over)
7790
Rev. 02/2014
Check () any of the following illnesses which the child has had:
Asthma
 Earaches
 Measles (red)
 Tonsillitis
 Bronchitis
 Eczema
 Mumps
 Whooping cough
 Chicken pox
 Frequent colds
 Pneumonia
 Other ________________________________
 Convulsions
 Influenza
 Polio
_____________________________________
 Croup
 Injuries
 Rheumatic fever
 Diphtheria
 Measles (German)
 Scarlet fever
List all known allergies:
Drug
Food
Other
List all medications taken on a regular basis:
List all known medical conditions:
List any concerns/limitations in regards to this child's medical treatment:
7790
Rev. 02/2014

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