Preschool Health Risk Waiver Form

Child's Full Name

First NameLast Name

Date of Birth

Date

Age

Gender

Classroom / Group Name

Parent/Guardian Full Name

First NameMiddle NameLast Name

Relationship to Child

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Primary Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Secondary Parent/Guardian Full Name

First NameMiddle NameLast Name

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Email Address

example@example.com

Emergency Contact 1 Name

First NameLast Name

Emergency Contact 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Emergency Contact Name

First NameLast Name

Alternate Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Child’s Physician/Pediatrician Name

First NameLast Name

Physician/Pediatrician Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Known Allergies

Current Medications and Dosage Instructions

Existing Medical Conditions or Special Considerations

Mobility, Diet, or Care Restrictions for Preschool Activities

Does the child carry an inhaler, EpiPen, or other emergency medication?

I understand and agree to the health risk waiver and authorization statement

Parent/Guardian Signature