The Chapel Christian Preschool
Emergency, Medical, and Parent / Guardian Releases
Child’s Name
Birth Date
Gender
Age
Nickname
City
State
Zip
Home Phone
Primary Email
Church
Address
Father’s Name
Cell Phone
Address
Home Phone
Email
Employer/WK Schedule
Work Phone
Address
Job Title
Mother’s Name
Cell Phone
Address
Home Phone
Email
Employer/WK Schedule
Work Phone
Address
Job Title
Emergency Contact #1 (other than parent)
Cell Phone
Person
Home Phone
Address
Relationship To Child
Emergency Contact #2 (other than parent)
Cell Phone
Person
Home Phone
Address
Relationship To Child
Medical Information
List any special problems that your child may have, such as allergies, existing illnesses,
previous serious illnesses, injuries and hospitalizations during the past 12 months, any
medications prescribed for long-term continuous use, and any other information which
our staff should be aware of:
Hospital Preference
Medical Insurance Provider
Group #
Policy #
Child’s Doctor
Phone
Address
Child’s Dentist
Phone
Address
Parent / Guardian Signature____________________________________ Date____________
Medical Treatment Release
By signing this form, you authorize The Chapel Christian Preschool to call an emergency
ambulance in case of accident or acute illness and to arrange for necessary emergency medical
care in case you are not immediately available. Any qualified physician called by The Chapel
Christian Preschool may treat your child and do whatever is necessary for his or her health and
well-being. You agree to accept responsibility for the cost of any medical services. Every effort
will be made to notify you before such action is taken.
Parent / Guardian Signature___________________________ Date________________
The Chapel Christian Preschool
Immunization and Past Illnesses
Child’s Name
Age
Date
Date of last physical exam ______________________
Immunization
DTP
Td
Polio
MMR
Measles
Rubella
Mumps
Influenza
TB Test
Chicken Pox
Date
Date
Date
Date
Date
Medical History
Past Illnesses (Please check any illness your child has and give approximate dates.)
Chicken pox
Rubeola
Rubella
Asthma
Hay fever
Diabetes
Poliomyelitis
Epilepsy/Seizures
Mumps
Rheumatic fever
Whooping cough
Premature birth
Speech / Hearing
Vision
Other
If you marked any of the above, please explain _______________________________________
_____________________________________________________________________________
List any medications ____________________________________________________________
_____________________________________________________________________________
Parent / Guardian Signature_________________________________ Date_______________