Corrigan Care Child Information Form
If you have more than one child in our program, please fill this out for each child.
Are you new to Corrigan Care?
How did you hear about Corrigan Care?
Your answer
Child's Full Name
Your answer
Child's Gender
Date of Birth
MM
/
DD
/
YYYY
Does this Child need a nurse to care for them?
Child's Diagnosis(ses)
Your answer
Child's Siblings (including ages
Your answer
OPTIONAL - for grants that we apply for - Racial Demographic
OPTIONAL - for grants that we apply for - Religious Affiliation
Parent/Guardian’s Name
Your answer
Email Address
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
County
Your answer
Primary Cell Phone - Name of person
Your answer
Secondary Phone - Name of person
Your answer
Emergency Contact Person - FULL NAME
Your answer
Emergency Contact Person - Relationship to Child?
Your answer
Emergency Contact Person - Phone Number
Your answer
AUTHORIZED PICKUP PERSON - Full Name(s)
Your answer
AUTHORIZED PICKUP PERSON - Relationship(s) to Child
Your answer
AUTHORIZED PICKUP PERSON - Phone Number(s) & Name(s)
Your answer
Does your child WALK INDEPENDENTLY?
If NO, please list any equipment ((AFOs walker, crutches, wheelchair, stroller, etc.)
Your answer
Is your child VERBAL?
If NO, indicate their communication style/method
Your answer
Does your child have aggressive tendencies?
Does your child have self-injurious tendencies?
Does your child require physical restraint for safety?
Does your child put things in their mouth?
If you answered YES to any of the above 6 questions, please explain here.
If NOs, then just enter N/A
Your answer
TOILETING NEEDS
Required
FEEDING NEEDS
please bring supplies needed and instructions if applicable
Required
Does your child...?
please explain
Required
Can your child sit in a chair at table safely?
Your answer
Can your child...?
Required
Does your child have any particular fears (noise, strangers, etc)?
If yes, suggested calming techniques? Any other safety concerns?
Your answer
List ALL life threatening allergies and treatment
(include food, drugs, plants, insects, latex, etc )
Your answer
List ALL other allergies and food sensitivities
hay fever, etc.
Your answer
List special dietary restrictions
GFCF, Ketogenic, etc.
Your answer
List ALL medications to be given
All medications should be in their original Rx container w/accurate dosage instructions.
Your answer
Any additional information on medical care?
(holding breath, head banging, past medical issues)
Your answer
HAS YOUR CHILD EVER HAD A SEIZURE?
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