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Get ND SFN 847 2008-2024

PARENT S STATEMENT ON HEALTH OF CHILD Clear Fields ND DEPARTMENT OF HUMAN SERVICES/CFS SFN 847 Rev. 11-2008 INSTRUCTIONS This form must be completed annually for any child enrolled in a licensed early childhood facility. This form is completed by a parent or guardian of the child. Full Legal Name of Child Birth Date Enrollment Date Please check one Dropin Relationship Address Home Telephone Number FT B/A School City Work Telephone Number State ZIP Code Family Dentist Family Physician Clinic Telephone Number Hospital Last Visit to Doctor Child s Height Does The Child Have Any food medication or environmental allergies Yes No Describe Allergy Reaction If Yes List Allergies Usual Treatment Please Check If Any Of The Following Conditions Exist Asthma Heart Condition Hearing Impairment Behavioral Issues Diabetes Seizure Disorder Frequent Earaches Other Conditions please specify Vision Impairment Please Explain All Checked Items Is The Child Under Current Medical Treatment If yes please list Are There Any Medications That The Child Takes Daily Describe Any Limitation Your Child May Have For Participation In An Early Childhood Program Is there a health care plan for your child No If yes please attach INSURANCE Liability insurance is not a requirement for a license to provide family or group child care. Please review with your child care provider the liability coverage that is presently in place. CERTIFICATION I certify that the above information is true to the best of my knowledge. This form is completed by a parent or guardian of the child. Full Legal Name of Child Birth Date Enrollment Date Please check one Dropin Relationship Address Home Telephone Number FT B/A School City Work Telephone Number State ZIP Code Family Dentist Family Physician Clinic Telephone Number Hospital Last Visit to Doctor Child s Height Does The Child Have Any food medication or environmental allergies Yes No Describe Allergy Reaction If Yes List Allergies Usual Treatment Please Check If Any Of The Following Conditions Exist Asthma Heart Condition Hearing Impairment Behavioral Issues Diabetes Seizure Disorder Frequent Earaches Other Conditions please specify Vision Impairment Please Explain All Checked Items Is The Child Under Current Medical Treatment If yes please list Are There Any Medications That The Child Takes Daily Describe Any Limitation Your Child May Have For Participation In An Early Childhood Program Is there a health care plan for your child No If yes please attach INSURANCE Liability insurance is not a requirement for a license to provide family or group child care. Please review with your child care provider the liability coverage that is presently in place. CERTIFICATION I certify that the above information is true to the best of my knowledge. .

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