Child Profile Form Page 2
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4EMERGENCY CONTACTS (Not including parents/guardians)
1. Name _____________________________ Address ______________________________________
Telephone # _______________________ Relationship __________________________________
2. Name ____________________________ Address ______________________________________
Telephone # _______________________ Relationship __________________________________
PRESCHOOL/CHILD CARE HISTORY
Has your child attended preschool/child care before? Yes_________ No ____________
If yes, for how long? 6 months ______ 1 year ______ 2 years _______ more than 2 years ____________
CHILD HEALTH RECORD
Immunizations: In accordance with regulation 12(2) of the Public Health Act, proof of immunization must be
provided for each child attending a child day care centre for the following:
diptheria
rubella
mumps
tetanus
varicella
measles
polio
meningococcal disease
Haemophilus influenza type B
pertussis
pneumococcal disease
Where proof is not provided you must have the following waivers:
a medical exemption, on a form provided by the Minister, that is signed by a medical practitioner or nurse
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practitioner, or
a written statement, on a form provided by the Minister, signed by the parent or legal guardian of his or
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her objections to the immunizations required by the Minister.
Note: Public Health will periodically review child files to ensure immunizations are complete or waivers are
present
Medical History:
Health Status:
Please indicate if your child has had any of the following: Indicate if your child has any of the following:
Medical History
Yes
No
Health Status
Yes
No
Measles
Asthma
Rubella
Diabetes
Mumps
Eczema/Psoriasis
Chicken Pox
Epilepsy/Seizures
Meningitis
Other
Pertussis (Whooping
Cough)
Medical Treatment: Please indicate medical treatment your child may require.
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