Caring For Kids Private Home Daycare Medical Form
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1CARING FOR KIDS PRIVATE HOME DAYCARE
MEDICAL FORM
CHILD INFORMATION
Surname: _____________________________________________
Male □ Female □
Given Name(S): _____________________________ Birth Date: _________________ (D/M/Y)
DOCTOR/MEDICAL INFORMATION
Doctor’s Name _________________________________________________________________________________
Address: ______________________________________________________________________________________
Apt/Unit #: _____________
City/Town: ________________ Province: ________________________________
Postal Code: ___________________
Telephone Number: ____________________________________
HISTORY OF COMMUNICABLE DISEASE
Chicken Pox
□ Mumps □ Measles □ Whooping Cough
□ Rubella (German measles)
□
□ Hepatitis
□ Scarlet Fever
IMMUNIZATION SCHEDULE
A copy of your child’s yellow immunization schedule MUST be provided before starting Daycare.
DPTP-HIB4
MMR
2 months
4 months
6 months
18 months
4-6 year booster
12months
18 months or 5 year
ALLERGIES:
If your child has an allergy(ies), please indicate below:
Allergy
Mild
Moderate
Severe
Life Threatening
If your child has a life threatening allergy please fill out Anaphylactic Action Plan prior to start date (please ask
Consultant for copy).
MEDICAL CONDITIONS: If your child has asthma or any other medical condition such as epilepsy, diabetes,
disabilities or reactions to drugs which could be a complicating factor (please inform Consultant).
MEDICATIONS: Is your child on any regular prescription medication? If yes, please describe__________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____________
Date: ___________________
Signature of Parent/Guardian: ______________________
Caring for kids, 130 Dundas Street East, Suite 303, Mississauga, Ontario, L5A 3V8
Dec 2010
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