Early Childhood Programs Application Form Page 4
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4The Campagna Center
Early Childhood Programs
Alexandria Head Start/Early Head Start
Important Medical Information
Child’s Name: ____________________________ Date: ____________________________
To ensure the health and safety of all students, please provide the following information about your child.
• My child takes prescription medication on a regular schedule.
Yes
No
• My child has an Epi-Pen (epinephrine injection).
Yes
No
• My child has an Inhaler.
Yes
No
• My child has medically diagnosed asthma.
Yes
No
• My child has medically diagnosed diabetes.
Yes
No
• My child has medically diagnosed seizures.
Yes
No
• My child has medically diagnosed allergies.
Yes
No
Type of allergies: _________________________________________________
• My child has medically diagnosed dietary restrictions.
Yes
No
Type of dietary restrictions: ________________________________________
• My child has religious dietary restrictions.
Yes
No
Type of religious dietary restrictions: _________________________________
• My child has a chronic medical condition not listed above:
Yes
No
Please explain: _________________________________________________________
______________________________________________________________________
• My child is under the care of a physician for the following conditions: _____________
______________________________________________________________________
______________________________________________________________________
Parent/Guardian Signature: ___________________________
Date: __________________
Verifying Staff Signature: _____________________________
Printed Name: ______________________________________
**If the answer is “Yes” to any of these questions, please have the parent submit the appropriate forms.
(Chronic Health Conditions and Health Plan, Permission to Administer Medication, Statement for Special Diet
Prescription)
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