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Child Medical Information Form

* is mandatory field

Child Information

* Child's Name

Birth Date (Optional)

* Parent's Name

Parents phone number (Optional)

Area

Local

Address (Optional)

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

-- Select country --

Physician Information

* Physician's Name

Phone (Optional)

Area

Local

Address (Optional)

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

-- Select country --

Health Information

Please indicate any specific medical conditions your child may have. (Optional)

Please indicate any specific medical conditions your child may have.

Sign of Symptoms to look for (Optional)

How Should The Staff Respond (Optional)

Medications

Please List any all medications that your child takes on a regular basis. Also, list the time of day that the medication is to be administreted

1. (Optional)

2. (Optional)

Emergency Contact Information

Emergency Contact Number (Optional)

Area

Local

Relation to Child (Optional)

i understand that in the event that my child becomes ill or injured, every effort will be made to reach me or the emergency contact listed above. I give my consent to act on my behalf to attain emergency care and / or treatment if believed necessary.

Date (Optional)

Signature (Optional)