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TEXAS TECH UNIVERSITY CHILD DEVELOPMENT RESEARCH CENTER
MEDICAL INFORMATION
We are required by the State of Texas (Child Care Licensing Law 746.611) to have the following information
completed within one week of the child’s date of admission. If not received within that period of time, your
child must be excluded from participation until this information is received.
Child’s Name: __________________________________________ Date of Birth: ___________________
Physician’s Name: ___________________________________
Address: ________________________________________________ Phone: ____________________
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To be completed and signed by child’s physician:
Please list any physical or emotional conditions that have been diagnosed during a routine screening
which would:
a. need special attention by the teacher due to disabling or limiting conditions
b. limit the child’s participation in school activities
Recommendations for care:
I certify that the above-named child is in good physical condition, is free from any communicable diseases, and
is physically able to participate in all school activities.
Physician’s Signature: ____________________________________ Date _________________
TEXAS TECH UNIVERSITY CHILD DEVELOPMENT RESEARCH CENTER
MEDICAL INFORMATION
We are required by the State of Texas (Child Care Licensing Law 746.611) to have the following information
completed within one week of the child’s date of admission. If not received within that period of time, your
child must be excluded from participation until this information is received.
Child’s Name: __________________________________________ Date of Birth: ___________________
Physician’s Name: ___________________________________
Address: ________________________________________________ Phone: ____________________
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Medical Information to be Completed & Signed by Parent
Please list all past or present major, communicable, serious or chronic illnesses (i.e. jaundice, mumps, diabetes, etc.)
and/or past major injuries, operations and hospitalizations.
Illness:
age
injuries:
age
operations:
age
hospitalizations:
age
please list any special needs your child has and treatment(s) currently provided:
list any allergies to food, animals, etc. and reactions:
allergic to:
Reaction:
To Be Completed by Parent (cont.):
list any other specific information regarding diet or medications prescribed for long-term use:
frequent Illnesses:
1colds 1tonsillitis 1vomiting 1ear-ache 1stomach aches 1high fever
1other______________________
current health problems under treatment:
Name & telephone number of any medical specialists seeing your child:
child’s dentist:
Name: ____________________________________________________________
Phone: ___________________
date of last visit: _________________________
list any additional information concerning your child’s health:
Acknowledgements:
My child’s medical and/or developmental history may be shared among CDRC administration and my child’s classroom teachers.
The CDRC professional staff will determine when and what information is necessary and relevant to share with students enrolled in the
educational program and that are working directly with my child. Any food allergies will be posted in the child’s room and any other
food preparation area.
If my child is or becomes concurrently enrolled in the ECI DEBT program or is receiving therapy from a private, licensed practitioner,
the CDRC staff may share developmental information and observations regarding my child with the practitioner.
Medical and developmental information will not be shared with anyone (other than those included on consent form) unless specific
written permission is obtained or as required by law.
Parent’s Signature: ____________________________________ Date _____________________
☺ PLEASE ATTACH A COPY OF CURRENT IMMUNIZATION RECORD ☺
According to Child Care Licensing Law 746.613 and 746.621
All immunizations required for your child’s age must be completed by the time of enrollment and
documentation provided to the center. A child may be provisionally enrolled and allowed to attend for up to 30
days if the parent can provide written documentation from a health-care professional that the child has
received at least one immunization in each series required for their age group and a statement of when the
remaining required immunizations will be completed.