SMILE PRESCHOOL AND NURSERY APPLICATION

YOUR CHILD'S HEALTH
Child's health record: A copy of your child's immunizations and current physical will be needed.
GENERAL STATEMENT OF HEALTH
DOCTOR'S NAME

First Name Last Name
Phone Number

Area Code Phone Number
DENTIST NAME

First Name Last Name
Phone Number

Area Code Phone Number
IS YOUR CHILD'S IMMUNIZATIONS UP TO DATE?

YES NO
PLEASE UPLOAD A SCANNED SIGNED COPY OF YOUR CHILD'S IMMUNIZATION RECORD

DOES YOUR CHILD HAVE ALLERGIES?

YES NO UNKNOWN
DO YOU THINK YOUR CHILD MAY HAVE ALLERGIES TO ANYTHING? IF SO, PLEASE NAME WHAT IT IS.
DOES YOUR CHILD HAVE ANY MEDICAL CONDITIONS THAT WE SHOULD BE AWARE OF?

WILL YOUR CHILD BE RELIED UPON TO INDICATE BATHROOM WISHES? PLEASE EXPLAIN IN DETAIL.
WHAT WORDS DOES YOUR CHILD USE FOR BOWEL MOVEMENTS AND URINATION?
HAS YOUR CHILD HAD EXPERIENCE PLAYING WITH OTHER CHILDREN?

YES NO
WHAT LANGUAGES ARE SPOKEN AT YOUR HOME?
DOES YOUR CHILD HAVE ANY SECURITY OBJECTS SUCH AS BLANKETS, SOOTHER, BOTTLE, TOY, ETC? IF SO, PLEASE TELL US.
ARE THERE ANY OTHER COMMENTS OR INFORMATION YOU WOULD LIKE TO LET US KNOW ABOUT YOUR CHILD?
ARE THERE ANY SPECIFIC CONCERNS WE NEED TO KNOW?
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YOUR CHILD'S HEALTH