Childcare Health Intake Form

Childcare Health Intake Form
Please complete this form to provide important health and emergency information for your child.
Child's Full Name
First NameLast Name
Child's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Full Name
First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child (Emergency Contact)
Does your child have any allergies?
If yes, please list all allergies and describe reactions.
Does your child have any chronic medical conditions or special needs?
If yes, please describe the condition(s) and any special care required.
Is your child currently taking any medications?
If yes, please list medications and instructions for administration.
Has your child received all recommended immunizations for their age?
Primary Physician's Name and Phone Number
Health Insurance Provider (if applicable)
Additional Notes or Special Instructions
Parent/Guardian Signature
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