HPS Early Childhood Programs Allergy, Medical, and Specific Concerns
Please complete the following information so that the Early Childhood Programs is aware of specific accommodations/medical information, and any custodial information we should know concerning your child. More detailed information and forms will be provided as needed, dependent on the information provided below.
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Email *
Student Name (Last, First) *
Parent(s) Name (Last, First) *
Parent Contact Information (phone number, email; best way to contact you?) *
Teacher / Program *
Complete section below with specific details and/or if not applicable, write NA
Description of allergy, medical condition, and/or special accommodations including all major or minor allergies (i.e. diagnosis of special needs, ASD, ADHD, peanut allergy, seizure, asthma, etc) *
Medications/Equipment needed at school (i.e. epipen, Benadryl, inhalor, wheel chair, etc) *
Custodial Arrangements - please share custody schedule (court documentation must be provided to the office prior to first day of care) *
Thank you for your help with this important information.  
Further information or contact may be conducted by the school, depending on student and family needs shared above.
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