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Child Information Form

Child Information Form

Child Details

Child Information

Child Details

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Parent 1

Parent 1

Parent 2

Parent 2

Medical Information

Medical Information

Birth 2 mo 4 mo 6 mo 12 mo 18 mo 4 yrs
Hepatitis B
Diphtheria
Tetanus
Pertussis
Polio
Hib
Pneumococcal
Rotavirus
Measles
Mumps
Rubella
Meningococcal C
Varicella

Emergency/Authorised Contact

Emergency/Authorised Contact
other than parent. Please include anyone who might collect your child from our centre.

Person 1:

This person has the authority to:
This person has the authority to:
This person has the authority to:

Authorisations

Authorisations

I hereby authorise Yeshivah/Beth Rivka OSHC staff and/or volunteers to photograph my child and use the photographs for any Yeshiva Beth Rivka OSHC for the following purposes:
Sign on the line with your mouse or finger