EMERGENCY HEALTH INFORMATION
CHILD’S IMMUNIZATION STATUS
CONSENT FOR EMERGENCY CARE
INJURY(S), ILLNESS(ES) OR OPERATIONS YOUR CHILD HAS HAD INCLUDE DATE(S)
1. Please describe any concern(s) / issues regarding your child’s health (seizures, asthma, vision, hearing,
2. Please describe any concerns you may have regarding your child’s development (Behaviour, vision,
hearing, speech, language, mobility. Etc.)
3. Please any specific care instruction regarding 1) and/or2) above.
(e.g. occupational therapist/ physical
ALTERNATE PERSONS AU
ALTERNATE PERSONS AUTHORIZED TO PICK UP CHILD
(other than parent/ guardian listed above,
include emergency pickup) Check all that apply
PERSONS WHO ARE NOT PERMITTED ACCESS TO MY CHILD
SIGNATURE OF PARENT OR GURDIAN PROVIDING INFORMATION
NOTE: This information may be reviewed by Fraser Health Licensing staff as per legislation.