CHILD'S HEALTH INFORMATION FORM

CHILD'S HEALTH RECORD

General state of health:
_______________________________________________________________
_______________________________________________________________
Are your child's immunizations up to date? YES ~ NO (Please attach a copy of immunizations.
This should include the signature of nurse or doctor who administered medications.)
Does your child have any known allergies?
_______________________________________________________________
Are you concerned that your child may be prone to any type of allergies?
YES ~ NO
If so, please specify and describe:
_______________________________________________________________
Does your child have any medical conditions which I should be made aware of?
________________________________________________________________
_________________________________________________________________
Has your child had the following common childhood illnesses? If yes, circle.
Chicken Pox
Measles
Whooping Cough
German Measles
Mumps
Other
Is your child prone to:
Ear Infections
Headaches
Stomach upsets
Colds
Sore throats

Does your child have any speech, hearing or visual difficulties?

__________________________________________________________________
Has your child ever been tested for any of the above?
__________________________________________________________________
Has your child ever had any surgeries or do they have any prosthetic limbs etc?
__________________________________________________________________
If yes, please describe:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

I s there any other information you can give me pertinent to your childs health which I should be aware
of in order to provide the best care for your child.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Signature of parent_______________________________________________________________

Signature of parent_______________________________________________________________
Provider's Name: Shirley Bressette- Angels In Training Childcare

EMERGENCY CARE & TRANSPORTATION FORM

PARENTAL CONSENT FOR EMERGENCY CARE AND TRANSPORTATION
Provider's Name: Shirley Bressette - Angels In Training Childcare
Child's First & Last Name: _________________________________________
Child's Date of Birth: ______________________________
Current Date: _________________________________
If at any time, due to such circumstances as an injury or sudden illness, medical treatment is necessary, I
authorize my childcare provider Valerie Griffin to take whatever emergency measures she deems
necessary for the protection of my child while in her care.
I understand this may involve calling a physician, interpreting and carrying out his or her instructions,
and transporting my child to a hospital or medical facility, including the possible use of an ambulance.
If possible, the hospital will be ________________________________________
or the physician's office will be (include physician's name and address)
________________________________________________________________
Second hospital of preference:
________________________________________________________________
I understand that this may be done prior to contacting me, and that any expense incurred for such
treatment, including ambulance fees, is my responsibility.
My child's Health Card Number is:
__________________________________________________
Version: _______________ Expiry:
______________________________________________________________________
Parent's Signature
__________________________________________________
Parents Signature
__________________________________________________
Provider's Signature

Medical Release:
I do hereby authorize Shirley Bressette
to contact the persons named on this card,
and do authorize the named physician or
his associates to render such treatment
as may be deemed necessary in an
emergency, for the health of said child.
In the event that parents or guardians,
other persons named on this card cannot
be reached, Shirley Bressette is hereby
authorized to take whatever action is
deemed necessary in the judgment for
the health of aforesaid child. Any expenses
incurred for the above will be the
responsibility of the parent,
not Shirley Bressette.
I HAVE READ THIS CARD AND AGREE
TO THE STATEMENT AS WRITTEN:
Date ______________________

_______________________________________________________
Signature of parent/guardian

_______________________________________________________
Signature of parent/guardian
_______________________________________________________
Emergency contact / phone number

Copy of OHIP card attached

EMERGENCY CONTACTS
EMERGENCY FORM
Provider's Name: Shirley Bressette- Angels In Training Childcare
Child's First & Last Name: _______________________________________________
Child's Date of Birth: ______________________________
Mother's First & Last Name (or Guardian):
____________________________________________________________________
Address: ____________________________________________________________
Phone: _____(___________)___________________________________________
Company Name & Address:
___________________________________________________________________
Hours: __________a.m. to ________p.m.
Phone & extension: ____(__________)____________________________________
Cellular phone: __(_______)________________ Pager: __(______)____________

Father's First & Last Name (or Guardian):

____________________________________________________________________
Address: ____________________________________________________________
Phone: _____(___________)___________________________________________
Company Name & Address:
___________________________________________________________________
Hours: __________a.m. to ________p.m.
Phone & extension: ____(__________)____________________________________
Cellular phone: __(_______)________________ Pager: __(______)____________

IF ABOVE PERSONS ARE NOT AVAILABLE: Names and addresses of persons to be contacted and to whom
the child may be released (must give three contacts):
Name: ______________________________________________________________
Relationship to child: __________________________________________________
Address: ____________________________________________________________
Phone at work: ___(__________)_______________________ext:_______________
Home telephone: ___(_________)________________________________________
Cellular phone: __(_______)________________ Pager: __(______)____________
Name: ______________________________________________________________
Relationship to child: __________________________________________________
Address: ____________________________________________________________
Phone at work: ___(__________)_______________________ext:_______________
Home telephone: ___(_________)________________________________________
Cellular phone: __(_______)________________ Pager: __(______)____________
Name: ______________________________________________________________
Relationship to child: __________________________________________________
Address: ____________________________________________________________
Phone at work: ___(__________)_______________________ext:_______________
Home telephone: ___(_________)________________________________________
Cellular phone: __(_______)________________ Pager: __(______)____________
Name: ______________________________________________________________
Relationship to child: __________________________________________________
Address: ____________________________________________________________
Phone at work: ___(__________)_______________________ext:_______________
Home telephone: ___(_________)________________________________________

Cellular phone: __(_______)________________ Pager: __(______)____________