Child Health - A to Z Building Blocks Early Care and Education

Child Health Form confidential

Name(Required)

First Name Last Name

Child's date of birth(Required)

Does your child have any known allergies or sensitivities to?

Document or place N/A

Medications(Required)

Foods(Required)

Other(Required)

Does your child have any known illness or medical conditions?

Document all that apply

Check all that apply

Asthma

Seizures

Heart Problems

Behavior/Emotional Problems

Visual Impariment

Physical Impariment

Developmental Delays

List any additional health information or special instructions you feel we need to be aware of:(Required)

List any regular medications your child takes:(Required)

Are your child’s immunizations up to date? If not what is he/she missing and when will the immunization be given:(Required)

Name of child’s medical provider:

Phone Number:

I agree to this form(Required)

Agree

Do Not Agree

Electronic Signature(Required)

Today's Date(Required)

Email Address(Required)

CAPTCHA

Draper

Spanish Fork

Child Health Form confidential

Does your child have any known allergies or sensitivities to?

Does your child have any known illness or medical conditions?

AMERICAN FORK

OREM

EAGLE MOUNTAIN

DRAPER

Have Questions?

Draper

Spanish Fork

Child Health Form *confidential*

Does your child have any known allergies or sensitivities to?

Does your child have any known illness or medical conditions?

AMERICAN FORK

OREM

EAGLE MOUNTAIN

DRAPER

Have Questions?

Child Health Form confidential