1625 Martin Bluff Rd

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Family Registration

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Family Registration

PARENT 1

PARENT 2

Person(s) to contact in case of emergency/Authorized to pick up child:

Names of other children in family:

Are your Child’s immunizations up to date?

Yes

No

Does child have any known health problems?

Yes

No

Check (√) any of the following illnesses the child has had:

Asthma

Earaches

Mumps

Whooping Cough

Bronchitis

Eczema

Pneumonia

Chicken Pox

Frequent Colds

Croup

Convulsions

Measles

Influenza

Rheumatic Fever

Diphtheria

Tonsillitis

Does you child have any know allergies

Yes

No

Does your child take any medication on a regular basis?

Yes

No

Do you have any concerns about your child’s development?

Yes

No

I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency. (Ambulance fees and/or health care costs are the responsibility of the parent/guardian)

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