LIFE Christian Academy KinderLIFE
Kid’s LIFE Christian Preschool Life Fellowship of Frederick 451 Oak Street, Suite 100 Frederick, CO 80530 Director: Katherine Busbee 727-421-9039 Church website: lifefrederick.org Email: [email protected]
Health Form Please use black or blue ink when filling out this form. STUDENT NAME: _______________________________________________________
AGE: ___________________
DATE OF BIRTH: ________ / ______ /______ HEIGHT: _____________ WEIGHT: __________ GENDER: ___________ PARENT #1: _________________________________PARENT #2: ____________________________________________
DOES YOUR CHILD HAVE ANY ALLERGIES? __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD THE FOLLOWING ILLNESSES? PLEASE SPECIFY DATES: __CHICKEN POX __RUBEOLA __RUBELLA __ASTHMA __ MUMPS __ EPILEPSY __ POLIO __RHEUMATIC FEVER __DIABETES __STREP THROAT __WHOOPING COUGH __OTHER. IF ‘OTHER’, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD ANY SURGERIES/ ACCIDENTS/ CHRONIC OR DISABILITY CONDITIONS __YES __NO IF YES, PLEASE SPECIFY: ________________________________________________________________________________
DOES YOUR CHILD TAKE ANY MEDICATIONS: __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD ANY DRUG REACTIONS? __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ DOES YOUR CHILD WEAR GLASSES? __YES __NO DOES YOUR CHILD WEAR A HEARING AID? __YES __NO DOES YOUR CHILD REQUIRE SPECIAL ASSISTANCE FROM PRESCHOOL STAFF?
__YES __NO IF YES, PLEASE SPECIFY:
______________________________________________________________________________________ ARE YOUR CHILD’S IMMUNIZATIONS UP TO DATE? __ YES __ NO (COPY OF RECORDS MUST BE GIVEN TO THE PRESCHOOL BEFORE CHILD MAY ATTEND.
COLORADO DEPT. OF PUBLIC HEALTH AND ENVIRONMENT – CERTIFICATE OF IMMUNIZATION
FORMS AVAILABLE UPON REQUEST)
*THIS INFORMATION IS CONSIDERED CURRENT FOR 365 DAYS FROM DATE OF SIGNATURE. I ATTEST THAT ALL INFORMATION ON THIS FORM IS ACCURATE. PARENT/GUARDIAN SIGNATURE:
*DATE
Health Form Please use black or blue ink when filling out this form. STUDENT NAME: _______________________________________________________
AGE: ___________________
DATE OF BIRTH: ________ / ______ /______ HEIGHT: _____________ WEIGHT: __________ GENDER: ___________ PARENT #1: _________________________________PARENT #2: ____________________________________________
DOES YOUR CHILD HAVE ANY ALLERGIES? __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD THE FOLLOWING ILLNESSES? PLEASE SPECIFY DATES: __CHICKEN POX __RUBEOLA __RUBELLA __ASTHMA __ MUMPS __ EPILEPSY __ POLIO __RHEUMATIC FEVER __DIABETES __STREP THROAT __WHOOPING COUGH __OTHER. IF ‘OTHER’, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD ANY SURGERIES/ ACCIDENTS/ CHRONIC OR DISABILITY CONDITIONS __YES __NO IF YES, PLEASE SPECIFY: ________________________________________________________________________________
DOES YOUR CHILD TAKE ANY MEDICATIONS: __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ HAS YOUR CHILD HAD ANY DRUG REACTIONS? __YES __NO IF YES, PLEASE SPECIFY: ______________________________________________________________________________________ DOES YOUR CHILD WEAR GLASSES? __YES __NO DOES YOUR CHILD WEAR A HEARING AID? __YES __NO DOES YOUR CHILD REQUIRE SPECIAL ASSISTANCE FROM PRESCHOOL STAFF?
__YES __NO IF YES, PLEASE SPECIFY:
______________________________________________________________________________________ ARE YOUR CHILD’S IMMUNIZATIONS UP TO DATE? __ YES __ NO (COPY OF RECORDS MUST BE GIVEN TO THE PRESCHOOL BEFORE CHILD MAY ATTEND.
COLORADO DEPT. OF PUBLIC HEALTH AND ENVIRONMENT – CERTIFICATE OF IMMUNIZATION
FORMS AVAILABLE UPON REQUEST)
*THIS INFORMATION IS CONSIDERED CURRENT FOR 365 DAYS FROM DATE OF SIGNATURE. I ATTEST THAT ALL INFORMATION ON THIS FORM IS ACCURATE. PARENT/GUARDIAN SIGNATURE:
*DATE
