Child's Contact & Medical Information

Child's First Name

Mother's Name

Mother's Email

Mother's Mobile

Last Name

Father's Name

Father's Email

Father's Mobile

Child's Medical History

Child's Date of Birth

Is Child Allergic to Anything?

Yes

Previous Hospitalizations or Surgeries

Yes

Is your child experiencing any mental or emotional challenges?

Yes

Should child's activites be limited?

Yes

If you answered yes, please elaborate

A PHYSICAL EXAMINATION must be completed and signed by a licensed physician, their authorized agent currently approved by the N.C. Board of Medical Examiners (or a comparable board from bordering states), a certified nurse practitioner, or a public health nurse meeting DHHS standards for EPSDT program. Please upload a signed and dated examination and child's IMMUNIZATION RECORD.

Upload Physical & Immunization

Parent Signature

Today's Date

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