Family Name *

Name of Child(s) *

Date of Birth *

/ /

Child Date of Birth *

/ /

Phone *

Email *

Alternate emergency contacts:

Name *

Relationship to child *

Phone *

Name

Relationship to child

Phone

Please give details (name, address and phone number)
of other persons who you authorise
to collect your child/ren in your absence,
while in the care Transformation Kids:

Are there any family situations
we should be aware of?
Ex: custodial issues, other matters
(please specify)

Confidential Medical Report

Specify

Is your child presently taking medication?
Yes / No If yes,
please state the name of the medication, dosage, etc

Does your child self-administer? Y / N

Is your child allergic to:

Penicillin

bee stings

Other drugs or food (please specify)

Please list any physical or special needs: (ex. Dietary requirements)

What is your child/ren T- shirt size?

1

Small
Medium
Large

2

Small
Medium
Large

3

Small
Medium
Large

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