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Please complete, print and fax these pages to: 617.732.9544

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 # _____________________________

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 check below to tell us about your child's current care arrangements

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

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

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:__________________________________________________________________________

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

____________________________________________________________________________________________________________

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:___________________________________________________
                                                 PRINT: _______________________________ 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:________________________________

Periodically, we will take photographs of children at the BWH Backup Child Care Center. Generally, photos will be used for three purposes: internally, for photo displays at the center; externally, for marketing the center to prospective families (photo albums, display boards, presentations); and occasionally, in BWH marketing publications, such as the Bulletin and a Partners Child Care Services web site. At no time, will a child's name or identity be listed without separate written parental consent.

If you consent to the above please complete the section below.

I hereby authorize Partners HealthCare System and its assigns to use the photograph/ video tape or any other visual medium of my child(ren) ____________________________________________, and any reproductions thereof in such manner, and in such publications as it may from time to time determine for the purpose of general reporting and promotion of Partners HealthCare System and the BWH Backup Child Care Center program, and for other educational and charitable purposes. I hereby release and discharge said company and its assigns from any and all liability in connection with such publication and use.

As parent or guardian of the above named person, I consent to the above release signature thereto and to the uses therein set forth.
Parent/Guardian’s Name: __________________________Parent/Guardian’s Signature: ________________________

Witness: _______________________________ Date:______________________

I give the BWH Backup Child Care Center permission to apply the following topical diaper ointment:

Name of diaper ointment: __________________________ Child's name: __________________________________

Date: From: ________________to:________________

All diaper ointments must be labeled clearly with the child’s first and last name and given directly to a Teacher.

I give the BWH Backup Child Care Center permission to apply the following topical sunscreen:

Name of sunscreen: ____________________________ Child's name: ___________________________________

Date: From:___________________ to:_______________
All sunscreens must be labeled clearly with the child’s first and last name and given directly to a Teacher.

Special Instructions:
__________________________________________________________________________________________

PARENT/ GUARDIAN SIGNATURE:__________________________

PRINT NAME: __________________________ DATE: _______