UMBC Angel's Suite Nursery Child Health Information Record
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Age
*
Child's Gender
*
Please Select
Female
Male
Parent/Guardian
Parent/Guardian
*
First Name
Last Name
Parent/Guardian - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Parent/Guardian - Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian - Email
*
example@example.com
Parent/Guardian - Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Getting Familiar With Your Child
Please select the preferred bottle option, if applicable
*
When fed
Pre-Prepared
Warmed
Cold
N/A
Is your child allowed to have snacks?
*
Yes
No
Does your child have allergies? Including food allergies?
*
Yes
No
Please specify what your child is allergic to.
What are the favorite activities for your child?
What annoys your child the most?
In Case of Emergency
By signing below, I give permission to Union Missionary Baptist Church Angel's Suite Nursery to secure emergency medical and/or emergency surgical treatment of the above-named minor while in this facility's care.
Physician's Name
First Name
Last Name
Physician or Clinic's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital Preferred for Emergency Treatment
*
Please list medications that your child is currently taking. Include dosage and time taken.
*
Please check if any of the following medical conditions apply:
*
No Medical Conditions
ADHD/ADD
Autistic
Asthma
ADHD/ADD
Cancer
Cerebral Palsy
Congenital Abnormality
Diabetes
Disabilities
Epilepsy
Eczema
Hard of Hearing
Heart Condition
Sight Complications
Other
Who has the authority to pick up your child from the nursery?
Person 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Person 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PRINT - Parent/Guardian Name
*
SIGNATURE - Parent/Guardian Name
*
Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Continue
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