Medical and allergy form

Child

• Full name
• Date of birth
• Program and days
• Parent or guardian name and phone

Allergies

• Food allergies and reactions
• Other allergies (insect stings, medications, latex) and reactions
• Epinephrine auto-injector (EpiPen) needed? Will it come to the program every day?
• Can your child use it on their own, or will staff hold it?

Medications

• Medication, dose and times
• Medication, dose and times
• Medications staff will give during the program (we may ask you and your child's doctor to sign our medication form)

Medical conditions

• Conditions staff should know about (such as asthma, diabetes or seizures)
• What staff should do if symptoms appear

Other needs

• Dietary needs
• Behavioral, learning or sensory needs (and what helps your child)

Doctor and insurance

• Doctor's name and phone
• Health insurance company and policy or member ID

Health records

• Immunization record or physical exam attached (if the program asks for it)

Emergency contacts

• Name, relationship, phone
• Name, relationship, phone

Consent for emergency care

In an emergency, staff will call 911 if needed and contact me as soon as they can. If they can't reach me, I authorize program staff to get emergency medical care for my child, including ambulance transport and treatment by a doctor or hospital, and to share this form with the medical staff who treat my child.

• Parent or guardian's printed name
• Parent or guardian signature
• Date