Child Enrollment And Health History Page 2
ADVERTISEMENT
1
2
3Page 2 of 3
D. EMERGENCY CONTACT – The person to be notified in an emergency when parents / guardians cannot be reached.
Yes
No This person is authorized to pick up the child.
Where Reachable While Child is in Care
Relationship to Child
Name
Home Telephone
Cell Phone
Address (Street, City)
Telephone
E. PHYSICIAN OR MEDICAL FACILITY
Name
Address (Street, City, State, Zip Code)
Telephone Number
F. HEALTH HISTORY AND EMERGENCY CARE PLAN If available, attach any health care plan information from the child’s physician, therapist, etc.
1.
Check any special medical condition that your child may have.
No specific medical condition
Any disorder including Cognitively Disabled, LD, ADD, ADHD, or Autism
Asthma
Cerebral palsy / motor disorder
Diabetes
Epilepsy / seizure disorder
Gastrointestinal or feeding concerns including special diet and supplements. If the child has a medical condition, excluding food allergy, that requires a special diet including
nutrient concentrates and supplements, attach the written authorization from the child’s physician.
Milk allergy. If a child is allergic to milk, attach a statement from the medical professional indicating the acceptable alternative.
Food allergies – Specify food(s).
Non-food allergies – Specify.
Other condition(s) requiring special care – Specify.
2.
Triggers that may cause problems – Specify.
3.
Signs or symptoms to watch for – Specify.
DCF-F-DWSW13251-E (R. 04/2012)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal