ESCE - Preschool Medical Form

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2021-2022 School Year

This information is being collected for preschool purposes only so that we can meet any medical needs your child may have. The information will be made available to the preschool teacher only and will be kept in confidential files at the Society Office (ESCE).

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* Indicates required question

Child's Full Name *

Your answer

Doctor Name *

Your answer

Doctor Phone Number *

Your answer

Alberta Health Care Number *

Your answer

Is your child fully immunized? *

Yes

No

Are there any social/behavioural concerns we should be aware of?

Your answer

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