Health Form To assist us in providing the best possible care for your child, please complete this form carefully. Please note that this information will be kept in your child’s file and will be accessible to Stepping Stones staff only. Type or print clearly in CAPITAL LETTERS Child’s Details
Child’s Name Clinic/Doctor’s Name Date of Birth Telephone Number Immunisation Details (copy of vaccination record required)
Polio/OPV Hepatitis Diphtheria Diphtheria Petussis Measles) Child’s Health Information Does your child have any allergies? If yes, please provide details:-
Is your child on any regular medication? If yes, please provide details:-
Does your child have any speech, vision or respiratory Yes problems or any other health condition?
If yes, please provide details:-
Additional Information Does your child require special educational needs Yes support?
If yes, please provide details:- Stepping Stones is happy to accept children with mild special needs upon receipt of a full medical report and assessment prior to registration. Should the report suggest additional support then a qualified shadow teacher, approved by us, should be appointed prior to the child attending the nursery (costs to be paid by parents). (Domestic helpers/nannies would not be accepted as a substitute). Medicine/Medical Treatment Authorisation
I give permission for the following medication to be Paracetamol (or similar non- Yes given to my child as needed aspirin pain reliever)
First aid medication for minor Yes wounds/insect bites
I give Stepping Stones permission that in the event of an accident or an illness requiring immediate medical Yes attention, to take my child to the nearest hospital
Declaration Details I confirm that the information provided is accurate and acknowledge that should I have withheld any information then Stepping Stones reserve the right to withdraw my child from it’s programme
The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the preferred drug list (formulary) that is at the core of your prescription-drugbenefit plan. The list is not all-inclusive and does not guarantee coverage. In addition tousing this list, you are encouraged to ask your doctor to prescribe generic drugs wheneverappropriate. 2014 Express Script
FAMILY CAREGIVING STATISTICS Published by: More than one quarter (26.6%) of the adult population has provided care for a chronically ill,disabled or aged family member or friend during the past year. Based on current census data,that translates into more than 50 million people. Source: National Family Caregivers Association (NFCA) RandomSample Survey of 1000 Adults, Funded by CareThere.co