Raleigh Nursery School

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70th Anniversary
Admissions Process
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Home
Who We Are
Partners
Educational Environment
About
70th Anniversary
Admissions Process
Forms & Documents
Resources
Contact

Medical Report

Name of Child *

Name of Child

First Name

Last Name

Birthdate *

Birthdate

YYYY

Name of Parent or Guardian *

Name of Parent or Guardian

First Name

Last Name

Address of Parent or Guardian *

Address of Parent or Guardian

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical History

May be completed by parent.

Is child allergic to anything? *

Yes

If yes, please explain.

Is child currently under a doctor's care? *

Yes

If yes, for what reason?

Is the child on any continuous medication? *

Yes

If yes, what?

Any previous hospitalizations or operations? *

Yes

If yes, when and for what?

Any history of significant previous diseases or recurrent illness? *

Yes

Diabetes? *

Yes

Convulsions? *

Yes

Heart Trouble? *

Yes

Asthma? *

Yes

If yes or Others, list what and when.

Does the child have any physical disabilities? *

Yes

If yes, please describe

Any mental disabilities? *

Yes

If yes, please describe

Acknowledgement of Parent or Guardian

You acknowledge that all information provided in the Children's Medical Report Form is complete and accurate to the best of your ability.

Parent or Guardian Name *

Parent or Guardian Name

First Name

Last Name

Parent or Guardian Contact Number *

Parent or Guardian Contact Number

(###)

###

####

Parent or Guardian Email Address *

Thank you for completing the Children’s Medical Report for Raleigh Nursery School! A member of Raleigh Nursery School will reach out to you with additional information about our Admissions Process.

Remember you will also need to have the Physical Examination and Immunization History documents completed as well. You can find that information in our Forms & Documents section.

Thank you for your time today - we look forward to meeting you and your young loved ones!

Raleigh Nursery School

Back To Forms & Docs

Admissions Process

70th Anniversary

Raleigh Nursery School, Inc.
1035 Halifax Street Raleigh, NC 27604
919-834-2136