Nursery – Medical Information Form

Living Word Baptist Church

Nursery

Medical Information Form

Child’s Full Name ______________________________________________________

Address _______________________________________________________________

City __________________St.________ Zip _______________ Phone ___________

Date of Birth ______________________

 

Parent/Guardian’s Full Name ___________________________________________

Address _______________________________________________________________

City __________________________ St._________ Zip ________________________

Home Phone ________________________ Work Phone _____________________

Cell Phone ____________________________

 

Alternate Emergency Contact Person (Someone with different address and phone number.)

Name _________________________________________________________________

Address_______________________________________________________________

City ________________ St. ___________ Zip ____________ Phone ____________

 

Doctor ___________________________ Phone ______________________

Address ______________________________ Zip ____________________

 

Health History

Allergies:         Food ____________________________________________________

____________________________________________________

Insect Stings ____________________________________________

Drugs ___________________________________________________

Other ___________________________________________________

 

Other Conditions:

___  Heart Condition

___  Chronic Condition

___  Diabetes

___  Physical Handicap (please List ):_____________________________________

___  Epilepsy

___  Other (please list ):__________________________________________________

 

If you checked any of the health conditions or allergies listed above, please give details (i.e., include normal treatment of allergy reactions.)____________________________________________

 

Date of Last Tetanus Shot _____________________________________________________