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Linden Heights
Baptist Church "The Church With Open Arms" |
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| LINDEN HEIGHTS BAPTIST CHURCH CHILD INFORMATION SHEET We are very happy to have your child as a part of Linden Heights Baptist Church. This sheet will help us better care for the needs of your child while he or she is here. If you have any questions or concerns please let us know.
Child’s Name__________________________________________________
Name the child goes by__________________________________________
Name of parent or who brings child_________________________________
Address_______________________________________________________
Phone_______________________
Child’s Grade ______ Child’s Age________
Child’s Birthday_______________
Medical Needs:
Food Allergies ________________________________________________
Allergies to Medication _________________________________________
Other Allergies ________________________________________________
Special Instructions ____________________________________________
Any thing else we should know __________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________
MEDICAL AND EMERGENCY CARE INFORMATION-LHBC
NAME_________________________________________________________DOB___________________
ADDRESS_____________________________________________________________________________
SS#_____________________________
PARENT OR GUARDIAN NAME_________________________________________________________
EMERGENCY CONTACT: NAME_______________________________________________________
RELATIONSHIP TO CHILD____________________________________________________________
PHONE #______________CELL PHONE #_______________WORK#______________
CHURCH THEY ATTEND______________________________________________________________
ADDRESS______________________________________________________PHONE #______________
HEALTH INSURANCE CO. NAME________________________________________________________
MEDICARE _____ MEDICAID _____ POLICY NUMBER_____________________________________
PLEASE INDICATE ANY HEALTH PROBLEMS:
KNOWN ALLERGIES REQUIRING MEDICATION: WHAT MEDICATION? ____________ FOOD________________________________________WHAT HAPPENS? ________________ INSECT______________________________________ WHAT HAPPENS? ________________ MEDICATION_________________________________ WHAT HAPPENS? ________________ OTHER ________________________________________________________________________
PLEASE CHECK ALL THAT APPLY:
ASTHMA_____ ADD/ADHD _____ BONE/JOINT PROBLEM _____ DIABETES _____ HEARING LOSS _____ MIGRAINE HEADACHES _____ NERVE/MUSCLE PROBLEM_____ PSYCHIATRIC/EMOTIONAL PROBLEM _____ SEIZURES _____ STOMACH PROBLEM_____ COLON PROBLEM _____ VISION PROBLEM _____ NONE _____
MEDICATIONS TAKEN DAILY: 1) ___________________________2) __________________________ 3) ___________________________ 4) ____________________________ 5) _______________________
DATE OF LAST TETANUS SHOT_________________________________________________________
THE CHURCH HAS MY PERMISSION IN AN EMERGENCY TO CALL THE RESCUE SQUAD OR TAKE MY CHILD TO THE NEAREST HOSPITAL EMERGENCY DEPARTMENT. THE HOSPITAL STAFF HAS MY AUTHORIZATION TO PROVIDE TREATMENT WHICH IS DEEMED NECESSARY FOR MY CHILD’S WELL BEING.
SIGNATURE________________________________________________DATE____________________
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Send mail to
WebAdmin@LindenHeightsBC.com with questions or comments about this web site.
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