Medical Form SECTION 2 | MEDICAL FORM * indicates required field Child's Name* Pediatrician's Name Pediatrician's Phone Preferred Hospital* Hospital Phone* Hospital Address* Insurance Co. Policy # Group # Expiration Date Food Allergies* Drug Allergies* Insect Allergies* Chronic Conditions* Special Needs* If you answered yes to any of the above allergies or conditions, further medical documentation may be required.* Understood Prescribed Medications* Serious Medical Conditions/Surgeries within the last 12 months* Standing order for the application of parent-provided non-prescription, topical medications, creams, lotions. *Parents must fill out a daily authorization sheet for non-prescription or prescription or topical medications other than sunscreen. Understood Sunscreen Preference (Pump lotions only. No aerosol sprays.) As per our policy, Kidinc Preschool requires a current copy of immunization records. It is the parent’s responsibility to provide updated shot records. Failure to do so may result in an interruption of services. Please attach your child's immunization record here. (Otherwise, please bring a printed copy.) Acceptable file types: doc,docx,pdf,txt,gif,jpg,jpeg,png.Maximum file size: 1mb. In the event that my child should become ill or sustain an injury while in the care of Kidinc Preschool, I/we give permission to the person(s) in charge to take whatever steps are necessary to obtain the required medical treatment for my child.* Agreed Parent/Guardian Name* Date* CAPTCHA Code:*