Childcare Health Compliance Assessment
Please complete this assessment to ensure your child's health information is up to date for childcare compliance.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Immunization Status
*
Up to date
Not up to date
Exempt (medical/religious)
Allergies (please specify all known allergies)
Does your child have any chronic medical conditions?
*
No
Asthma
Diabetes
Epilepsy
Other (please specify below)
If you selected 'Other' above, please specify the condition:
Has your child experienced any of the following symptoms in the past 14 days?
*
Fever
Cough
Shortness of breath
Sore throat
Vomiting or diarrhea
None of the above
Please rate your child's overall health in the past month.
1
2
3
4
5
Medications currently taken (please list all medications, dosages, and times)
Additional health information or special instructions for staff
Parent/Guardian Signature
*
Submit Assessment
Submit Assessment
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