Medical Information — Completed by Parent or Guardian — Please Print
Child’s Name _________________________________________________ Birth date ______/ _____/ ______
Child’s Soc. Sec. # *_______________________________
Allergies ___________________________________________________________________________________
Medications ________________________________________________________________________________
Chronic Conditions (e.g. epilepsy, diabetes) _______________________________________________________
Medical Insurance Co. _______________________________________ Policy No. _______________________
Member’s Name ____________________________________ Phone: (h) ______________ (w) _____________
Member’s Birth date ______/ _____/ ______ Member’s Soc. Sec. # *__________________________________
Family Doctor ______________________________________ Phone __________________________________
* Social Security number is optional. Please note that some hospitals WILL NOT treat without it.
ACTIVITY INFORMATION
On-Going Program
Church Agency: St. James of the Valley Program or Group: PSR/PEP_________
Starting Date: August 26, 2007 Ending Date: May 11, 2007 Registration Fee: Varies
Usual Location: 411 Springfield Pk. Usual day and time: Sundays, 9:45am – 12:00pm
Routine Activities: Normal classroom activities__________________________________
Group Leader: Angela A. Glassmeyer Telephone No.: 513-385-0386
Other Information_____________________________________________________________
__Ö___ Check here if any additional information is attached. (Note: any additional activity information (e.g. schedule, list of specific activities, etc.) may be attached to further inform parents(s) or guardian(s).