Medical Form — King's Kids Preschool

Medical/Emergency Form

Your child’s safety is our first priority. Please fill out the following information so we know who to contact in case of an emergency and any pertinent medical information.

Child's Name

First Name

Last Name

Child's Doctor

First Name

Last Name

Doctor's Phone Number

(###)

###

####

Doctor's Office Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Whom may we call in case of an emergency?

Emergency Contact #1 (Parent or Guardian)

First Name

Last Name

Phone

(###)

###

####

Emergency Contact #2 (Parent or Guardian)

First Name

Last Name

Phone

(###)

###

####

I give my permission to take my child to the hospital should this be necessary.

Yes

In case we are unable to reach you, whom else may we call in case of an emergency? (Grandparent, neighbor, etc)

Alternative Contact #1

First Name

Last Name

Phone

(###)

###

####

Relationship to child

Alternative Contact #2

First Name

Last Name

Phone

(###)

###

####

Relationship to child

Alternative Contact #3

First Name

Last Name

Phone

(###)

###

####

Relationship to child

Does the child have any allergies? If so, what is the medication and what limitations should be placed upon him/her at preschool?

Is the child subject to any condition which may make for a classroom emergency, such as epilepsy, convulsions, allergies, diabetes, etc? If yes, please provide more information:

Is there any physical condition which would limit classroom or activity participation? If yes, please comment:

My child's immunizations are current as required (If you select no, you MUST provide a written explanation from your child's primary care doctor. This must be provided to us ASAP).

Yes

Medical/Emergency Form

Info

King’s Kids Preschool