24-25 Before/After Care Registration

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School Age Assessment/Health Form/ Immunization Declaration

Email *

Child's Full Name

Childs Birth Date *

YYYY

Significant Illnesses and Surgeries child has had (give age and date) *

Any Special health-related needs of child ( allergies, medications, injuries, etc) *

Is there any defect of vision, hearing or speech of which the child care program should be aware, or could compensate by appropriate action? *

Is this child subject to any conditions which limit classroom activities or physical education? *

Is this child subject to any condition which may results in an emergency situation? *

Is this child subject to any mental or physical condition for which he/she should remain under periodic medical observation? *

Date of Last Tetanus:

YYYY

Other Information you would like to share about your child? *

My Signature below certifies that immunization information concerning my child has been provided and is available in the school file. *

Parental Emergency Medical Consent:

This form allows parents and guardians to authorized the provision of emergency treatment for the named child who becomes ill or injured while under program authority when parents or guardian cannot be reached:

In the event reasonable attempts to contact have been unsuccessful, I hereby give consent to the administration of any treatment deemed necessary by the doctor or dentist listed( on SPS school registration), or if unavailable, another licensed physician or dentist. I agree to pay all cost and fees as secured or authorized under this consent: (Signature and date)

Date Filled out *

YYYY

A copy of your responses will be emailed to the address you provided.

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