Child's Name: _______________________________________________________

Health Card Number: _______________________________________________________

Age: ______________________ Birthdate: ______________________

Home Civic Address: _______________________________________________________

Mailing Address: _______________________________________________________

Home Phone #: ______________________ Work #: ______________________

In Case of Emergency and Parent / Guardians Cannot Be Reached Please Notify:

Name: ______________________ Phone #: ______________________

Child's Doctor's Name: _______________________________________________________

Is Your Child on Medication?
YES_________ NO_________

Is Your Child Allergic to Foods, Bug Bites or Other Things That He or She
May Come In Contact With While On This Facility?
Please List: _______________________________________________________
___________________________________________________
___________________________________________________

Are There Any Medical Concerns We Should Be Aware Of:
Diabetes_______Headaches______Visual Problems______ Hearing Problems______
Other: _______________________________________________________

Recommended Response If Complaint Arises: _______________________________________________________
___________________________________________________
___________________________________________________

It Is Understood That Should Any Emergency Occur Every Attempt Will Be Made To Contact The Parent Or Guardian, Then The Emergency Contact. However, If For Any Reason Immediate Medical Attention Is Necessary For The Health And Safety Of The Child, Medical Attention Will Be Sought Be Calling 911.

______________________________
Parent Signature

______________________________
Date