Medical Registration Form

Child's Information
Child's name: (First, Middle, & Last) *

Email: *


Date of Birth*


Hight Weight Head Circumference


Has your child have any of the following conditions:


illness Conditions
ChickenPox  yes no Diabetes  yes no
Whooping Cough  yes no Epilepsy  yes no
German Measles (Rubella)  yes no Heart Trouble  yes no
Mumps  yes no Asthma  yes no
Rheumatic Fever  yes no Hearing difficulty  yes no
Scarlet Fever  yes no Vision difficulty  yes no
Tuberculosis  yes no Speech difficulty  yes no
Pneumonia  yes no Operations  yes no
Malaria  yes no Serious Injuries  yes no
Meningitis  yes no Allergies (specify below)  yes no
Other, please specify Other, please specify

If yes was chosen above, please mention what is your child allergic to? {Food - Medicine}

In the event of an emergency or accident, I authorize "My Baby Nursery" to take my child to the nearest Hospital/Clinic for emergency medical treatment. The Nursery will make every attempt to contact me or my emergency contact person. We shall also keep the Nursery updated of any changes in the above information relating to our child or to ourselves at all times.

 Yes No

Doctor's Name
Doctor's Contact Number
Vaccination Record