Child'S Health Resume

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_____________________________________________________________________________________________________
Child’s Health Resume
(Required Form)
Child Care Regulation 35 requires every licensee to keep a record with respect to each child attending the facility that
includes: (a) child’s name and date of birth, (b) names, addresses and telephone numbers of the child’s parents, persons
to contact in the case of an emergency and the child’s medical practitioner, (c) any allergies, illness or other medical
condition, and (d) the child’s immunization status.
Note: Personal health information may be disclosed by the facility to the Ministry of Education
in the course of reviewing the facility’s record keeping obligations.
Child’s name: _____________________________________________________________ Starting Date: ________/________/________
Year
Month
Day
Date of Birth: ________/________/________
Personal Health Number:________________________________________
Year
Month
Day
Group Medical Services or Medical Services Incorporated Number _________________________________________________________
Mother’s name: _________________________________________
Father’s name: ________________________________________
Home Address: __________________________________________
Home Address: ________________________________________
Postal Code: ____________________________________________
Postal Code: __________________________________________
Home phone: ___________________________________________
Home phone: _________________________________________
Place of business: ________________________________________
Place of business: ______________________________________
Business phone: _________________________________________
Business phone: _______________________________________
Cell phone: _____________________________________________
Cell phone: ___________________________________________
Email address: ___________________________________________
Email address: _________________________________________
Are both parents listed above authorized to remove the child from the child care facility?
 Yes
 No
Comments: _____________________________________________________________________________________________________
_______________________________________________________________________________________________________________
In case of emergency, the child care service will contact the following physician for medical treatment:
Physician’s name: ________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________
Phone: _________________________________________________________________________________________________________
Provide the names of two other persons to contact in case of emergency.
1. Name: ______________________________________________
2. Name: _____________________________________________
Relationship: _________________________________________
Relationship: _______________________________________
Home phone: _________________________________________
Home phone: _______________________________________
Business phone: _______________________________________
Business phone: _____________________________________
Cell phone: ___________________________________________
Cell phone: _________________________________________
Medical History
Check () any of the following illnesses which the child has had:
 Asthma
 Earaches
 Mumps
 Whooping cough
 Bronchitis
 Eczema
 Pneumonia
 Injuries – please list ___________________
 Chicken pox
 Frequent colds
 Polio
____________________________________
 Convulsions
 Influenza
 Rheumatic fever
 Other - please list _____________________
 Croup
 Measles (German)
 Scarlet fever
____________________________________
 Diphtheria
 Measles (red)
 Tonsillitis
____________________________________
(over)
7809 Rev. 02/2014

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