Child Registration Form - Canada

Please tell us anything else you think will help us provide an enriching experience for yo ur child: ________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
HEALTH INFORMATION
Health professionals involved with your child (other than doctor and dentist):
NAME PROFESSION/AGENCY
____________________________________ _________________________________________ Phone: __________________________
____________________________________ _________________________________________ Phone: __________________________
____________________________________ _________________________________________ Phone: __________________________
Does your child have:
A medical condition/concern? YES NO
If yes, please provide further information: __________________________________________________________________________________
Allergies? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Asthma? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Has your child had a seizure in the past year? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Does your child require a special diet related to a medical condition? YES
NO
If yes, please provide further information: __________________________________________________________________________________
Food sensitivities? YES
NO
If yes, please provide further information: __________________________________________________________________________________
List all prescription and “over the counter” medications your child receives:
Medication Times Given Reason for Medication
____________________________________ __________________________________ ___________________________________
________________________________________ __________________________________ ____________________________________
You may be asked to complete additional forms if you answered yes to any of the above.
This health information may be made available to the staff of Vancouver Coastal Health.
This health information may be made available to the staff of Vancouver Coastal Health.
Office Use Only
Date Child Leaves the Facility: DATE: ________/______/______
YY MM DD
Regional 2009 Provided by VCH COMMUNITY CARE FACILITIES LICENSING
Custody Agreement YES N/A Provided to Facility YES NO N/A
Immunization Documents Returned to Facility YES NO
Information Provided By: ______________________________ ________________________________
Print Name Signature
DATE: ________/______/______
YY MM DD
Information Received By
: ______________________________ ________________________________
Print Name Signature
DATE: ________/______/______
YY MM DD
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