H515 Child Care Facilities Registration Form (Page 2 of 2) in pdf

H515 Child Care Facilities Registration Form Page 2

HAS CHILD PREVIOUSLY ATTENDED DAYCARE/PRESCHOOL?

YES_________

NO __________

IF YES, WHERE? ______________________

COMMENTS/INSTRUCTIONS TO HELP US CARE FOR YOUR CHILD:

TOILETING/DIAPERING:______________________________________________________

REST TIME_________________________________________________________________

EATING/MEALTIME___________________________________________________________

FEARS_____________________________________________________________________

HEALTH INFORMATION

FAMILY DOCTOR:_________________________________ PHONE: ____________________

FAMILY DENTIST:________________________________ PHONE: ____________________

OTHER HEALTH PROFESSIONALS INVOLVED WITH YOUR CHILD:

_______________________________________________ PHONE: ____________________

CARECARE PERSONAL HEALTH NUMBER:

DATE EFFECTIVE:

_______________________________

______/______/______

YEAR

MONTH

DATE

IF APPROPRIATE, COMMENT ON THE FOLLOWING HEALTH ISSUES:

SPECIAL MEDICATIONS:______

VISION OR HEARING:_____

ALLERGIES: _______

SPEECH OR LANGUAGE:_______

OTHER:______

__________________________________________________________________________

PARENTS’ COMMENTS (IF ANY):

__________________________________________________________________________

This health information is to be made available to the staff of the

Vancouver Health Department.

I give my consent for my child to be involved in drop-in visits by the

Vancouver Health Department staff.

SIGNATURE OF PERSON PROVIDING INFORMATION:________________________________

SIGNATURE OF PERSON RECEIVING INFORMATION:________________________________

DATE:_______/_______/_______

YEAR

MONTH

DATE

EVE-4662.COV

H515 Child Care Facilities Registration Form Page 2