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Health Appraisal Form
Statement of current health of child and household. Please fill out even if child isn't sick. Answers will not exclude you from receiving child care.
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* Indicates required question
My Name:
*
Your answer
My Phone Number:
*
Your answer
Child's Name:
*
Your answer
Birthdate:
*
Your answer
Allergies, please describe or write NA:
*
Your answer
Type of reaction
Your answer
Diet:
Breast Fed
Formula
Age Approriate
Special Diet
Clear selection
Describe special diet:
Your answer
Please use this section to let us know about your child's current condition (what we need to know today) and any special instructions you would like us to follow:
*
Your answer
Name of Child's Healthcare Provider
*
Your answer
Healthcare Providers Phone:
*
Your answer
If there is an emergency and I cannot be reached, please contact:
*
Your answer
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