CHILD’S NAME:(Required) First BIRTHDATE(Required)Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Please attach child’s photo to this form(Required)Max. file size: 512 MB.ADDRESS:(Required) Street Address PARENT’S NAME:(Required) First HOME PHONE:CELL PHONE:(Required)WORK PHONE:PARENT’S NAME: First HOME PHONE:CELL PHONE:WORK PHONE:EMERGENCY CONTACT:(Required)CELL PHONE:(Required)PHONE:OUT OF TOWN CONTACT:(Required)PHONE:(Required)CHILD’S DOCTOR:(Required)PHONE:(Required)DATE OF MOST RECENT TETANUS SHOT:(Required)Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031ALLERGIES / MEDICATIONS:(Required)CHILD’S DENTIST:(Required)PHONE:(Required)CARE CARD NUMBER(Required)Consent(Required)1) It is the policy of this facility to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Our procedure is to call for an ambulance. 2) Please tick the consent below so that we can take the appropriate action on behalf of your child. Return the signed consent to the facility immediately. We will take this consent with us to the emergency centre. 3) I hereby give consent for my child taken to the nearest emergency centre when I cannot be contacted. 4) I hereby give consent for my child named above to receive medical treatment. I agree to the policy.
