Criminal Declaration Form Which Child Care Advisor have you been working with? *Please select your Child Care Advisor...ClairHediKatyeMargaretMeganSandraI can't rememberIf you have not been contacted by a Child Care Advisor yet, please select 'No Assigned Advisor'.Your Child's Full Name *Allergy Description *Symptoms: *Tingling, itching, swellingDifficulty breathingWeakness or dizzinessThroat tightnessChest tightnessStomach cramping, vomitingDifficulty swallowingSense of fearFeeling faintWheezing, coughingFlushing of the face and bodyHivesPlease select all that apply.Ongoing Instructions:What to avoid, practices to follow, if self-administration is required, etc.Does your child have an EpiPen Auto-Injector?YesNoExpiration date of AutoInjector (EpiPen) *Location of Auto-Injector at the Home Child CareParent/Guardian *Parent/Guardian Phone *Parent/Guardian Email Address *Emergency Contact *Emergency Contact Phone *Name of the Provider (or the alternate Provider) *Signature of Parent / Guardian *Start signing your signature hereYour browser does not support e-Signature field.Today's Date: *Submit
