Please complete the following health information and review our HIPAA policy at the end of this form 12 Child Name First Last Date of Birth Month Day Year Primary Parent/Guardian First Last Primary Contact #Primary Email Does your child have health insurance?YesNoWhat type of health insurance?Medicaid/Dr. DynasaurPrivateOtherPlease specify other insurance: Does your child have a Doctor?YesNoDoctor's Name or Medical Practice Doctor's Phone #Does your child have a Dentist?YesNoDentist's Name or Practice Dentist's Phone #Does your child have any health conditions?YesNoPlease List Conditions and Describe SymptomsDoes your child take any Medications?YesNoIs Medication needed on site?YesNoPlease list MedicationsDoes your child have any allergies (including medications, food, bee stings, etc.)?No Known AllergiesYesPlease List Allergies and Describe SymptomsCheck any of the following which apply to your child Autism Developmental Delay Emotional/Behavioral Disability Hearing Impairment / Deafness Impairment of Motor Function Visual Impairment / Blindness Other Health Impairment Please specify other Health Impairment My child has or has had(check if applicable) IEP IFSP Comprehensive Evaluation Most Recent Date Month Day Year Completed at/by: Please specify any concerns you may have about your child’s behavior or development: PERMISSION TO PICK UP/PERMISSION TO TRANSPORTBy signing on the Parent/Guardian signature line below, I give my permission for my child to be transported in the event of an emergency. Additionally, I give my permission for my child to be released to the following people for the purposes of pick-up and/or transportation to/from CVHS activity sites. (Include the child’s other parent and other family members who may be likely to transport the child.) The parent/guardian understands that his/her child will only be released to persons identified on the following list. Anyone who is unknown to CVHS staff must show identification. I give my permission for my child to be transported to and from CVHS activities by any transportation service with whom CVHS may contract for transportation of children in the CVHS program, and to release the name and address of my child to transportation services contracted by CVHS for the purpose of CVHS activities. In the event of an emergency, I authorize the staff or collaborative partners of Champlain Valley Head Start to seek any necessary treatment or emergency medical care for my child.Emergency Contacts: Vermont State Early Childhood Program Licensing Regulations require that at least two (2) emergency contacts, other than the legal parent(s)/guardian(s), be identified.Emergency Contact People must be able to transport the child in the event of an emergency if the CVHS parent or legal guardian cannot be reached. Emergency contacts must be aware they are designated as such. Emergency contacts unknown to CVHS staff must produce identification before a child is released.Emergency/Authorized Pickup Contact Name #1 First Last Type of Contact #1 Emergency Contact Authorized Pickup Contact #1 PhoneContact #1 Relationship to Child Contact #1 Address Street Address City State ZIP / Postal Code Emergency/Authorized Pickup Contact Name #2 First Last Type of Contact #2 Emergency Contact Authorized Pickup Contact #2 PhoneContact #2 Relationship to Child Contact #2 Address Street Address City State ZIP / Postal Code Emergency/Authorized Pickup Contact Name #3 First Last Type of Contact #3 Emergency Contact Authorized Pickup Contact #3 PhoneContact #3 Relationship to Child Contact #3 Address Street Address City State ZIP / Postal Code Emergency/Authorized Pickup Contact Name #4 First Last Type of Contact #4 Emergency Contact Authorized Pickup Contact #4 PhoneContact #4 Relationship to Child Contact #4 Address Street Address City State ZIP / Postal Code HIPAA Policy and Authorization AgreementPlease select the HIPAA privacy statement link to review our policy. Checking the box indicates your agreement to this policy. Your signature below provides authorization for pickup/transport and in the event of an emergency.Untitled First Choice Second Choice Third Choice Δ