Medical Form

Name of parent filling out form:

First Last

Your Email

Child's Name

First Last

Does this child have any food allergies?

No
Yes

Type of reaction:

Is an Epi-Pen required/prescribed by a doctor?

No
Yes

If yes, parent is responsible for providing the Epi-pen to be stored at school.

Does this child have any asthma?

No
Yes

Asthma triggers/symptoms

Is an inhaler required/prescribed by a doctor?

No
Yes

If yes, parent is responsible for providing the inhaler to be stored at school.

Does this child have any chronic or medical conditions/illnesses?

Seizures?
Cardiac Condition
Type 1 Diabetes
Type 2 Diabetes
Other

Other Condition, please specify:

Please list medications related to any health condition:

Please list any other important information to help us better care for your child while at school

This information is correct to the best of my knowledge. If parent cannot be notified and emergency care is necessary I hereby give my permission for this student to be transported to the nearest hospital and I give permission for the hospital to give emergency threaten as may be needed. I will assume responsiblity for all fees incurred by such emergency:

Initial Here*

Today's Date

Month

Day

Year

CAPTCHA

Medical Form

Preschool Medical Release Form

Kids Club House

Directions

Socialize With Us

Kids Club House offers 3 and 4-year-old preschool programs in the Warwick, NY area. We are just a short drive from Minisink, Florida, Greenwood Lake, Unionville, Slate Hill, Chester, Sugar Loaf and Monroe New York, as well as Vernon, Glenwood, Hardyston, Hamburg and Hewitt, New Jersey.