CHILD HEALTH STATEMENT FORM

Please fill out page 1 of this form and have your child’s healthcare provider sign and date page 2.We require an updated health statement form annually to continue enrollment. Please provide anupdated allergy/disease action plan annually if your child has any of the conditions listed on thisform. Additionally, we require up to date immunization information. Please provide an updatedrecord of immunization each time your child receives a vaccine.

Child’s name:

DOB:

Does your child have any of the following medical conditions

Other medical conditions/concerns:

Any regular medications:

Major medical conditions/hospitalizations within the past year (please give description & date):

Any other information regarding your child’s health, behavior, or development of which we shouldbe aware:

Primary care doctor:

Phone:

Address:

Does your child have health insurance?YesNo

Insurance company:

Policy/Member ID:

Emergency Treatment Authorization

Does your child have heaDo you authorize Kinectory Learning Centers® staff to give consent for emergency medicaltreatment and transportation in the event a parent/guardian cannot be reached?lth insurance?YesNo

Parent/Guardian Signature:

Date:

Healthcare Provider’s Statement

Child’s name:

DOB:

Healthcare provider/PCP name:_

Phone:

Address

I have examined the child listed on this form within the past year and have determined he/she isable to participate in the child-care program. (Must be within one year of the date of enrollment)

Signature:

Date:

Thank you! Your submission has been received!

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CHILD HEALTH STATEMENT FORM

Does your child have any of the following medical conditions

Emergency Treatment Authorization

Healthcare Provider’s Statement

I have examined the child listed on this form within the past year and have determined he/she isable to participate in the child-care program. (Must be within one year of the date of enrollment)