Little ABC Monkeys Daycare
Consent for Emergency Medical Treatment
_____________________________
(Child’s Name)
Parent/Legal Guardian: ____________________
Work Phone: _________________________
Address: ________________________________ Home Phone: _________________________
City: _______________ State: ____ Zip: ______ Cell Phone: _________________________
Parent/Legal Guardian: ____________________Work Phone: _________________________
Home Address: ___________________________ Home Phone: _________________________
City: _______________ State: ____ Zip: ______ Cell Phone: _________________________
Parent Insurance Information
Primary Insurance Company Name: ___________________________________________________
Primary Insured Name: _______________________________ Group #: _____________________
Identification #: __________ Group #: _________ Parent Social Security #: ___________________
Medical History of Child
Prescription Medication: _____________________________________________________________
Medical Condition: _________________________________________________________________
Allergies: ________________________________________________________________________
Doctor’s name and phone number: ____________________________________________________
Dentist’s name and phone number:____________________________________________________
As Parent, Legal Guardian or Authorized Representative, I hereby grant give my consent to
_____________________ and her substitute/assistant/second adult to provide all emergency
(Provider's Name)
medical or dental care prescribed by a duly licensed physician (M.D.) Osteopath (D.O.) or Dentist
(D.D.S.) for _______________________________. This care may be given under whatever
(Child’s Name)
conditions are necessary to preserve the life, limb or well being of the child named above.
The child has the following medication allergies: ________________________________________
_________________________________ __________________________________________
Date: Month, day, year Parent/Legal Guardian/or Authorized Representative Signature
ABOUT YOUR CHILD
Child’s name________________________________________________________________
DOB___________________________________ AGE_______________________________
1. What FOODS does your child especially like___________________________________
____________________________________________________________________________
____________________________________________________________________________
2. Especially DISLIKE?_______________________________________________________
____________________________________________________________________________
3. Favorite toys, games, activities?_______________________________________________
_____________________________________________________________________________
4. Is your child TOILET TRAINED?_______ What words does your child use for toilet?
____________________________________________________________________________
5. How does your child express ANGER or frustration? ____________________________
____________________________________________________________________________
6. Does your child have any special FEARS? ______________________________________
Explain______________________________________________________________________
7. When your child is upset, what helps to COMFORT him/her? _____________________
_____________________________________________________________________________
8. How do you DISCIPLINE your child? _________________________________________
_____________________________________________________________________________
9. Has your child been taking an afternoon NAP? ________ If so, how long? ___________
If not, why? __________________________________________________________________
10. Special toy or blanket for NAP? _____________________________________________
11. Special FAMILY situation? (such as custody specifications, problems arising from
situations, etc.) _______________________________________________________________
12. Anticipated ADJUSTMENT problems? _______________________________________
_____________________________________________________________________________
13. Any disorders/developmental (slow, advanced) diagnosed or suspected? ____________
_____________________________________________________________________________
14. Previous childcare child has attended? ________________________________________
_____________________________________________________________________________
15. Any problems at previous daycare? __________________________________________
_____________________________________________________________________________
16. EXPECTATIONS of Little ABC Monkeys Daycare?____________________________
_____________________________________________________________________________
17. Other COMMENTS? ______________________________________________________
_____________________________________________________________________________
HEALTH HISTORY
1. Are any medication given regularly? YES OR NO
What type of medication are given and how often does the child take it?________________
_____________________________________________________________________________
2. Any drug reaction? _________________________________________________________
3. Known Allergies? __________________________________________________________
4. Has your child been HOSPITALIZED? (EXPLAIN) _____________________________
_____________________________________________________________________________
5. Has your child ever had any surgeries? ________________________________________
_____________________________________________________________________________
6. Has your child had INJURIES with fractures or loss of consciousness? (EXPLAIN)
_____________________________________________________________________________
_____________________________________________________________________________
7. Illness: (please circle). Does your child have any problems with any of these? Has your child had any of these diseases?
Asthma Bronchitis Constipation
Chicken Pox Lice Diarrhea
Convulsions Hepatitis Measles
Diabetes Fainting Spells Mumps
Frequent Colds German Measles Frequent Ear Infections
Polio Ringworm Frequent Sore Throats
Heart Trouble Scarlet Fever Skin Rash
Tuberculosis Whooping Cough Stomach Upsets
Worms Urinary Impetigo
Upper Respiratory Infections
8. Other ILLNESSES? (Besides above) __________________________________________
