Child’s Full Name _____________________________________ Gender_________ Birthdate ____________________

Name on name tag ___________________________________ Class (Teacher/Days) ________________________________ Parent/Guardian’s Name ______________________________ Relationship ____________ Occupation _______________________ Parent/Guardian’s Name _______________________________Relationship _____________Occupation_______________________ Sibling ____________________Age ______Gender ______ Sibling _________ Age ______ Gender______ Sibling ____________________Age ______Gender ______ Sibling _________ Age______ Gender______ Family Pets ___________________________________________________________________________________ 1. Briefly describe your child’s personality: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 2. We want your child to have a positive preschool experience. Please help by listing any special needs (allergies, other medical concerns, social or academic challenges):_______________________________________________________________ ____________________________________________________________________________________________________________ 3. Which is your child’s dominant hand? Right Left Undetermined 4. Is your child toilet trained? (Required for children in all classes except twos) Yes No Working on it 5. My child’s immunizations are up to date. Yes No 6. Language(s) spoken at home: ____________________________________________ 7. Your child’s favorite games, toys and activities:____________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 8. What are the most important do’s and don’ts in your family and for your child? ___________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. What ways of setting limits or reinforcing family rules have you found most successful with your child? ________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. What do you hope your child gains from his or her preschool experience? ______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 11. Does your child have any special fears? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 12. Prior preschool experience (when and where), if any: ______________________________________________________________ Other Information:______________________________________________________________________________

2016-2017

CHILD PROFILE—Page 1

Return this form to the school.

����-���� &+,/'�352),/(—3DJH�� 5HWXUQ�WKLV�IRUP�WR�VFKRRO�� Child’s Name: _______________________________________ Class: __________________ Please list a minimum of two emergency contacts other than parents/guardians. We will make every effort to contact you in the event of an emergency. Should we not be able to get ahold of you, you authorize our staff to contact the following people. You may also authorize people other than your child’s parents/guardians to pick up your child from school. If someone not listed above is picking up your child, they must show their driver’s license as identification, which should correspond with the note given to the teacher at the beginning of class. If the information is conflicting, the teacher is not to let the child go until proper confirmation has been made. For each contact, check the appropriate boxes below. Your parent/guardian information is already on file. In the event there is a medical emergency involving my child during the school hours at New Life Christian Preschool, and I am unable to be contacted, I hereby give my permission for appropriate medical treatment to be given to my child by a licensed healthcare professional.

Doctor’s Name__________________________ Phone # ( )_________________ Preferred Hospital ___________________________________ Insurance Carrier/Number_____________________________________________________ Parents who choose to carpool and/or arrange rides with other children are required to have current auto insurance. Please provide the following information: Carrier: _________________________________ Policy #_______________________________ Legal Guardian’s Signature: _____________________________ Date: ____________________

Name 1: __________________________________________ Relationship: ________________ Phone #:__________________ <HV 1R

<HV 1R

Name 2: __________________________________________ Relationship: ________________ Phone #:__________________ <HV 1R

<HV 1R

Contact Information Does this person have permission to pickup your child? Is this person an emergency contact?

Name 3: __________________________________________ Relationship: ________________ Phone #:__________________ <HV 1R

<HV 1R

Name 4: __________________________________________ Relationship: ________________ Phone #:__________________ <HV 1R

<HV 1R

Information accessed by Child Care Health Program, Public Health – Seattle & King County 06/2004

_________________ Name Of Child/Patient Today’s Date

This child is enrolled in our preschool program. We have been advised that he/she is allergic or intolerant to the following foods:

1. 5. 2. 6. 3. 7.

4. 8.

Please help us to comply and meet the health needs of your patient by completing the Food Allergy/Intolerance Statement form and if necessary the Emergency Plan for Food Allergic Reactions. We need to know the foods the child is allergic or intolerant to, and the steps to take to treat an allergic reaction. Thank you for your help in this important health matter. Sincerely, Sue LaBrie New Life Christian Preschool Preschool Director Name of Preschool 22659 Sweeney Rd. SE, Maple Valley, WA 98038 425-432-5876 ext. 43 Preschool Address Phone Number By signing below, I indicate my approval to release the information requested above to my child’s preschool program. Parent’s Signature Date Parent’s Name (Please print)

Parent’s Address

Report of Food Allergies

Information accessed by Child Care Health Program, Public Health – Seattle & King County 06/2004

Name of Child _____________________________________Birthdate_____________

Name of Parent/Guardian _________________________ Phone _________________ Day/Evening

(Please print) List each food separately

Check the medical condition

Symptoms

Food Intolerance Yes No

Food Allergy *Yes No

Food Intolerance Yes No

Food Allergy *Yes No

Food Intolerance Yes No

Food Allergy *Yes No

Food Intolerance Yes No

Food Allergy *Yes No

Food Intolerance Yes No

Food Allergy *Yes No

* For A Food Allergy, Complete Emergency Plan for Food Allergic Response

Health Care Practitioner __________________________________________________

Signature of Practitioner _______________________________Date_______________

Mailing Address (Print or type) Phone __________________________

_ _______________________________

_ _______________________________

Please return to the child care program at the address listed below:

Food Allergy/Intolerance Statement

Information accessed by Child Care Health Program, Public Health – Seattle & King County 06/2004

Emergency Plan for Food Allergic Reactions

ALLERGY TO: ___________________________________________________________________________ Student’s Name: D.O.B:________________________ Asthma Yes* No *High Risk for severe reaction

ACTION FOR MINOR REACTION If symptom(s) are:__________________________________________________________________

◘◘◘◘ Call: Parent/Guardian or Doctor

◘ Administer with Parental/Dr’s permission:________________________________________ medication/dose/route

◘ If condition does not improve within 10 minutes, follow steps for Severe Reaction below:

ACTION FOR SEVERE REACTION If symptom(s) are:__________________________________________________________________

◘ Administer:______________________________________________________IMMEDIATELY! Medication/dose/route

◘ ◘ ◘ ◘ Call: 911 (Never hesitate to call 911)

◘◘◘◘ Call: Parent or Guardian

◘ ◘ ◘ ◘ Call: Doctor Parent/guardian _________________________________________ phone # _______________________ Parent/guardian _________________________________________ phone # _______________________ Doctor______________________________________________ phone #______________________ Parent/guardian signature_________________________________________ Date: ___________________ Doctor’s signature (Required) ______________________________________ Date: ___________________

SIGNS OF AN ALLERGIC REACTION Systems: Symptoms:

• MOUTH itching & swelling of the lips, tongue, or mouth

• THROAT itching and/or a sense of tightness in the throat, hoarseness and hacking cough

• SKIN hives, itchy rash, and/or swelling about the face or extremities

• GUT nausea, abdominal cramps, vomiting, and/or diarrhea

• LUNG shortness of breath, repetitive coughing, and/or wheezing

• HEART “thready” pulse, “passing-out”

The severity of symptoms can quickly change. All the above symptoms can potentially progress to a life-threatening situation.

Information accessed by Child Care Health Program, Public Health – Seattle & King County 06/2004

Emergency Contacts Trained Staff Members

1. 1. Room Relation: Phone 2. Room 2. 3. Room Relation: Phone 3. Relation: Phone

Do you consent to releasing your child’s food allergy information to the other preschool classroom parents? Their name and photo will posted in the class and a letter will be sent out. Yes No ___________________________________________________________

Parent’s Signature EPIPEN® and EPIPEN® Jr. Directions

1. Pull off gray activation cap.

2. Hold black tip near outer thigh (always apply to thigh).

3. Place firmly against thigh and press until Auto-injector mechanism functions. Hold in place and count to 10. The EpiPen unit should then be removed and taken with you to the Emergency Room. Massage the injection area for 20 seconds.