In order to give your child the best possible nursery health and emergency care, please complete this form carefully.
Child’s Information
 Full Name:     Date of Birth:                 
 Sex:               Language Spoken:       
 Nationality:  Emergency Contact No:

 All vaccination completed and up to date: YES

Other Medical Information
 Is your child under any kind of medication?
 Has your child ever been evaluated for learning problems?
 Has your child been assessed to have special physical, emotional, physiological or language needs?
 Does your child wear eye glasses?
 Does your child have a hearing difficulty?
 Does your child have any known allergy?
 Blood Type?
 Any past medical history?
Infection Diseases YES NO Non-Infectious Diseases YES NO
 Infective Hepatitis
 Bronchial Asthma
 Congenital Heart Disease
 Diabetes Mellitus
 Scarlet Fever
 Rheumatic Fever
 Surgical Operations
 Whooping Cough
 Chicken Pox

Permission for Medication: London and Paris International Nursery has my permission to give my child the following medication* if necessary in age appropriate dosages:


 * Paracetamol (Panadol or similar non-aspirin pain reliever; first aid medication for minor wounds or insect bites)

 The London and Paris International Nursery will not accept:

 - Children who are sick or suffering from infections

 - Children who have been sent home due to sickness and those who appear to be sick upon arrival, parents must
present a medical certificate.


 DATE:  Parents Signature: