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Please print out these pages and Fax to: 617.732.9544

Please complete

For Employee: ID # _______________________________ Dept._________________________________

For Patient: Blue Card #:___________________________ Dept. _________________________________

Child(ren)'s First & Last Names: (Please list all children in attendance)
1. ___________________________________________     DOB: ___-___-___   Gender: ____
2. ___________________________________________     DOB: ___-___-___   Gender: ____
3. ___________________________________________     DOB: ___-___-___   Gender: ____

Employee E-mail address at work: ________________________________________________

Parent/Guardian: #1_____________________________Work Phone # __________________

Beeper #_____________________________________ Cell Phone: _____________________

Home Address:____________________ Apt. # _________ Home Phone # __________________

City_____________________ State________________ Zip Code

Parent/Guardian: #2_____________________________Work Phone # __________________

Beeper #_____________________________________ Cell Phone: _____________________

Home Address:____________________ Apt. # _________ Home Phone # __________________

City_____________________ State________________ Zip Code_________________________

In the event that you leave your office or work area (i.e. lunch, meetings, etc.), who can we call to get in touch with you? Generally this person is a co-worker, administrative assistant, etc.

Name:____________________________________ Work Phone # _________________________

Please list and verbally alert us to any allergies your child may have to food, medication, etc.
Please check here if there are NO KNOWN ALLERGIES _______

Allergies:_________________________________ Reactions:______________________________

Special Notes Regarding Meals:_____________________________________________________

Child’s Primary Language:_________________________________________________

Primary Language Keywords that apply to your child's age/stage of development:

Milk __________________; Water _____________________; Juice __________________;

Bottle _________________; Hungry ___________________; Tired _________________;

Bathroom/Toilet ___________________; Diaper _______________;

If there are any other primary language words you feel would be helpful, please include them here:

Please list times of naps, special comfort items, as well as your usual routine for helping your child to sleep. _________________________________________________________________________________
_________________________________________________________________________________

Please list and verbally alert us to any medical or developmental condition that could require special care or attention.

________________________________________________________________________________________

Please tell us about your child's current care arrangements

_____ Family child care _____ Center-based child care _____ Family menber at home

_____ Nanny in home _____ Parent at home _____ Other. Please describe:

Comments:________________________________________________________________________

Any special instructions including ointments, wipes, powder, etc. Please note that in order for us to apply any topical's, you must first fill out a TOPICAL PERMISSION RELEASE. Please ask a teacher for this form.

Diapering: Usual Routine:________________________________________________________________

Toileting: Usual Routine:________________________________________________________________

Is your child currently taking any medications?__________________ If so, Why?________________

Name of medication ____________________________________________________

Please note: Staff can only administer prescription medication when it is in the original prescription container and accompanied by a completed AUTHORIZATION FOR MEDICATION, which we provide for you. Please ask a staff member about our specific medication policies so we can best serve you and your child.

It is essential to provide teachers with the above information at drop-off time, allowing them to offer the best possible care to your children. Please be sure to inform them of any unusual circumstances that might affect your child’s day. Thank you!

PLEASE GIVE ALL MEDICATIONS TO A TEACHER - NEVER LEAVE MEDICATIONS IN YOUR CHILD'S BAG OR CUBBY

PARENT/GUARDIAN SIGNATURE:________________________________
                                               PRINT:________________________________
                                                DATE:________________________________

NAME OF CHILD:________________________________________________________________

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child.

However, if I cannot be reached, I hereby authorize the BWH Backup Child Care Center to transport my child by ambulance to the nearest emergency room or ____________________________ (name of hospital preferred) and to secure for my child the necessary medical treatment including anesthesia. I understand the teachers in the BWH Backup Child Care Center are trained in the basics of First Aid and I authorize them to give my child First Aid when appropriate.

Is your child allergic to any medications? If so please state:

Allergy: _____________________________________ Reaction: _________________________

PARENT/GUARDIAN SIGNATURE:________________________________
                                                 DATE:________________________________

MEDICAL INSURANCE WITH:___________________________________________________

POLICY NUMBER:______________________________________________________________

DOCTOR'S NAME:______________________________________________________________

DOCTOR'S ADDRESS:___________________________________________________________

DOCTOR'S PHONE:_____________________________________________________________

CHILD'S BWH MEDICAL NUMBER: (if applicable) __________________________________

PARENT/GUARDIAN SIGNATURE:________________________________
                         PRINT FULL NAME:________________________________
                                                 DATE:________________________________