Emergency and Medical Informaton Form

EMERGENCY AND MEDICAL INFORMATON FORM

Child’s Name ______Birthday______Sex______Start Date______

School Age Children Only______

SchoolGrade

Primary residence of child is with:□Both Parents □Mother □Father □Other______

Are there any court orders/parenting plans in effect concerning the custody of the child?□Yes□No If so, please provide us with a copy of these documents prior to enrollment.

Is your family currently involved with the Division of Children and Family Services (DCFS)? Yes No

______(___)______(___)______

Mother/Guardian Name Home Phone Cell Phone Email Address

______(____)______

Address of MotherPlace of Employment Work Phone

______

I give consent to add my email address to the listserv to receive information from CCCC’s programs. □Yes □No

______(__)___(__)______

Father/Guardian Name Home Phone Cell Phone Email Address

______(_____)______

Address of FatherPlace of Employment Work Phone

I give consent to add my email address to the listserv to receive information from CCCC’s programs. □Yes □No

Local Emergency Contacts (These persons are authorized to pick up the child)

1.______(____)______

Name Relationship to Parent Phone Number(s)

2.______(____)______

Name Relationship to Parent Phone Number(s)

Physician/Dentist Information:

______(___)______(___)______Physician Name Phone Last Appt. Date Dentist Name Phone Last Appt. Date

*(if you do not have a Doctor or Dentist please let our staff know and we can provide you with a list of local providers)

Medical Insurance Information:

Company: ______Plan Number: ______

Allergy & Medical History

Permission for Emergency Treatment

At the time of an emergency, medical treatment is urgent. I authorize Community Child Care Center staff to call emergency aid (911) or transport my child to the nearest hospital or my child’s physician to receive immediate care. I also give permission for CCCC to give first aid for minor injuries. I understand that I will be responsible for all expenses connected with the seeking of emergency care.

Signature ______Date______

CHILD HEALTH HISTORY INFORMATION

1. Did the child’s Mother have regular prenatal care?

Yes

No

1. Were there any complications during the pregnancy?

Yes please specify: ______

No

1. Was your child born prematurely?

Yes, Birth weight ______pounds______ounces______length

No

1. Did the mother smoke during the pregnancy? Yes No

1. Did the mother use alcohol and drugs during the pregnancy? Yes No

1. Has your child had any chronic illness, disease, or disability?

Yes, please specify: ______

No

1. Does your child have any known allergies?

Yes, please specify: ______

No

1. Is your child taking any medications?

Yes, please specify: ______

No

(If your child does need medication while attending school, please be aware that you will need to have a medication administration form filled out by your physician before we can administer any medication to your child. Thank you.)

1. Do you have any concerns about your child’s hearing or vision?

Yes, please specify: ______

No

1. Do you have any concerns about your child’s speech?

Yes, please specify: ______

No

1. Do you have any concerns regarding your child’s weight?

Yes

No

1. Please check and concerns you have about your child from the list below:

Revised 2/2015