Name of Child. Grade: Teacher:
Name of Child. Signature: Date: Print Name: Relationship to Child: CHILD’S NAME BIRTH DATE ADDRESS MOTHER’S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER E-MAIL ADDRESS MOBILE TELEPHONE NUMBER ADDRESS BUSINESS NAME BUSINESS TELEPHONE NUMBER ADDRESS FATHER’S NAME/LEGAL GUARDIAN HOME TELEPHONE NUMBER
Name of Child. Grade: 8th Homeroom: School: Prairie Hills Junior High Laptop Description: Dell 3340
Examples of Name of Child in a sentence
I, , (Parent or Guardian’s Name) grant permission for my child, (Name of Child) to participate in school/parish events this year that may require transportation to a location away from the school/parish site.
Name of Child: ...................................................
Name of Child Date of Birth Name of School National Curriculum Year Group - Current Proposed Having read both the Department for Education and Dorset County Council Guidance on placement of children outside of their normal age group I wish to confirm that I have agreed for my child to be placed in the proposed National Curriculum Year Group.
Name of Child Physical Custody Awarded To Legal Custody Awarded To If you agreed to a shared physical custody arrangement, you must specify the custody schedule.
Name of Child Date of Birth Name of School Having read both the Department for Education and Dorset County Council Guidance on summer born children I wish to delay entry into reception until September (Enter appropriate year).
More Definitions of Name of Child
Name of Child. DOB: Age: Sex: Child’s health history and current health problems: Any special medical conditions, including chronic health problems: Any special medications and/or restrictions: Are your child’s immunizations up to date? If not, what is needed? Has your child had any of the following common childhood illnesses? Chicken pox yes no Measles yes no Whooping cough yes no German measles yes no Mumps yes no Rubella yes no Scarlet Fever yes no German measles yes no Rheumatic Fever yes no Is your child prone to: Ear infections yes no Headaches yes no Sore throats yes no Stomach upsets yes no Colds yes no Heart disease yes no Diabetes yes no Upper Respiratory Infections yes no Other: Does your child have any speech, hearing, or visual problems? Has your child ever been tested for any of the above? Describe: Has your child ever had any surgeries? Describe: Known medical problems: Last tetanus shot: / / Reaction?: Yes No Child’s Blood Type: Drug Reactions: Contact with Tuberculosis: TB Test (date): result Chest x-ray (date): result Sickle Cell Agreements: Test (date): result Allergies: When my child is ill, I understand and agree that One Step Up will not accept my child for care. This includes: fever, diarrhea, vomiting, bad cough, all cold spymptoms due to COVID-19 and discharge from nose/eyes of any color than clear, and all communicable diseases. My signature below certifies that my child is to my knowledge, in good health, and free of disabilities that would endanger him/her or other children. Also by signing below I agree that this is a legally binding form. Providing false information could be grounds for termination of childcare services, forfeiture of retainer, or both. Father/Guardian’s Signature Date Mother/Guardian’s Signature Date XxXxxx Xxxxxxxx/One Step Up Childcare Date Authorization for Emergency Medical Care If I cannot be reached to make arrangements for emergency medical care for my child at the time of an illness, accident, or injury, I give my permission for: One Step up - Childcare
Name of Child. Class: Date: Address: Illness: Name of Medicine: Any known side effects? Date Dispensed & Name of Doctor: Length of Treatment: Dosage: Time to be given: Any special Instructions/precautions? Can this be self-administered with adult supervision? YES / NO Name of Parent/Carer: Daytime Telephone No: Relationship to pupil: Address if different form the child: I understand and agree to: My child reporting to the appointed person at the prescribed time in order to receive their medication. Whilst every reasonable effort will be made to remind children to report for their medication, school will not be held responsible should a dose be missed. Medication will be given according to the instructions given by your child’s doctor, from their own clearly labelled medication. We are unable to administer any medication without such a label. Signature of Parent/Carer: Date:
Name of Child. (“Child”)
Name of Child. Class: Child’s signature:
Name of Child. Age: Name of Child: Age: Name of Child: Age: Name of Child: Age:
Name of Child. Age:___________ Sex: ______________ Health Card no.: Parent’s Contact: Emergency Contact: Date: ____________________________________ Date: ____________________________________ Child’s Name: ________________________________________________ Age:___________ Sex: ______________ Parent/Guardian Name: _______________________________________________________________________________ Provincial Health Card Number: _____________________________________________________________________ Family Physician’s Name: _____________________________________________________________________________ Address / Contact Number: ___________________________________________________________________________ _____________________________________________________________________________________________________________
Name of Child. Weight: Age: Height (in inches): Shoe Size: Name of Parent or Legal Guardian: Phone Number: Cell Phone Number: Address: City, State, Zip Code: Emergency Contact Name: Phone # Relationship to Child: