Emergency Form After School Care Ockenburgh

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Emergency Form After School Care Ockenburgh

Please fill this form as carefully and completely as possible in. It is of great importance for you, your child and the group management that we have the right information when it’s needed.

Important: Provide timely changes to the group management regarding accessibility and health insurance.

Date

Data Child

Name and Surname

Birth Date

Address

Zip Code / Place

Data Parents

Parent (1)

Name and Surname

Mobile Phone

Working Company

Phone Number Work

Parent (2)

Name and Surname

Mobile Phone

Working Company

Phone Number Work

Backup

(this person can be within half an hour at the After School Care if necessary)

Name and Surname

Address

Zip Code / Place

Mobile Phone

Health Insurance

Insurance Company

Insurance Number

General Practitioner

Name and Surname

Address

Zip Code / Place

Mobile Phone

Dentist

Name and Surname

Address

Zip Code / Place

Mobile Phone

Health and Nutrition

Does your child have a food allergy or intolerance?

Yes
No

If so for which foods?

Other nutritional details

Does your child have a different allergy?

Yes
No

If so, what is your child allergic to?

Does your child use medicines?

Yes
No

If so which medicines and for what?

May your child have a paracetamol for fever?

Yes
No

Does your child follow the vaccination program?

Yes
No

My child may / may not take part in trips of After School Care Ockenburgh

Yes
No

Other Details

Comment

After Schoolcare Ockenburgh – Ish

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