Required fields are marked with asterisks (*)

Welcome

Children Services and Early Learning Health Form.

Child's name

In Case of Emergency Contact (Name, Telephone #, Relationship to Child.

My Child can be Release to:

Other Children in the family: Please list Name, Age and Sex.

Other Adults living in the home: Please list Name and Relationship.

Billeting: As our winter weather is unpredictable, we need the name of a friend/relative in Wingham with whom your child could stay should he/she be stranded in town due to a storm. Please list Name, Address, Telephone # and Relationship to Child.

Health Information

Does your child suffer from any medical problems?

Yes

If yes, please list special instructions.

Has your child had Chickenpox?

Yes

Please list any special needs which the teachers should be aware of (ex. Special Equipment, etc.):

Does this child have any condition which might make for a classroom emergency, such as: convulsions, epilepsy, fainting, diabetes, asthma?

Does your child require prescription medication to be taken on a regular basis?

Yes

If yes, please describe.

Would any of the above prevent the child from engaging in normal school activities?