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Fire Circle Forms: Health Form

Fire Circle Forms

Child Health History

Please complete this form to tell us about your child’s health history. Please complete one form per child you are enrolling.

WE RECOMMEND THAT PARENTS AND LEGAL GUARDIANS OF HIGH-RISK CHILDREN CONSULT WITH THEIR CHILD’S MEDICAL PROVIDER TO ASSESS THEIR RISK AND DETERMINE IF THIS PROGRAM’S ATTENDANCE IS ACCEPTABLE.

YOU WILL HAVE TO COMPLETE AND UPLOAD EITHER IMMUNIZATION DOCUMENTATION OR IMMUNIZATION EXEMPTION AFTER COMPLETING THIS FORM

Health History

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Name (Child)*
First Last
Name (Parent/Gardian) - primary*
First Last
Phone*
Name (Parent/Gardian) - secondary
First Last
Phone
Child's Physician Name*
First Last
Child's Physician phone*

Health History
We want to ensure that your child’s experience is positive and successful. Please provide us with as much information and details that would be helpful to the health staff.
Does your Child have any physical health problems?*
- Yes
- No
If yes, please explain:*
Does your child take any medications?*
- Yes
- No
If yes, please explain:*
Does your child have any dietary restrictions?*
- Yes
- No
If yes, please explain:*
Does your child have any allergies?*
- Yes
- No
If yes, please explain:*
Does your child have any psychiatric health problems?*
- Yes
- No
If yes, please explain:*
Does your child have any behavioral health problems?*
- Yes
- No
If yes, please explain:*
In the past 12 months has your child seen a professional for any mental or emotional health concerns?*
- Yes
- No
If yes, please explain:*
Does your child have any special needs?*
- Yes
- No
Does your child have an IEP, 504 plan or behavior plan at school?*
- Yes
- No
If yes to either, please explain:*
Has your child gone through any significant changes or stresses at home or in school prior to the disruption of the school year due to COVID-19?
How has your child been handling the changes due to COVID-19?

MEDICAL INSURANCE INFORMATION:
This child is covered by family medical/hospital insurance*
- Yes
- No
Insurance Company Name*
Policy Number*
Policy Holder Name*
Insurance Company Phone Number*

IMMUNIZATION INFORMATION:
Must list current residence on Immunization form MDH-896.
For participants who currently reside within the United States, a United States territory, or the District of Columbia: Does the child have any immunization exemptions because of a medical contraindication?*
- Yes
- No
In these instances, please attach a letter from a licensed M.D or D.O documenting the problem and exempting the child from further doses of that specific vaccine. Documentation must list specific vaccinations. Vaccinations not listed on the form will require the completion of the MDH-896 form or documentation from doctor on vaccines received.
For all participantss, including those who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896 which can be downloaded from our main forms page. Alternatively, many doctors offices now make it possible to download your immunization records from their portal, we will accept those too. Please upload the completed immunization record or form on the document upload page
Name
First Last
Date
MM slash DD slash YYYY

SUNSCREEN:
Please be sure your child brings labeled sunscreen with them every day. Staff can only assist with application and re-application if parents sign below and provide the date & brand of sunscreen you are sending.
Due to COVID regulations, staff cannot help to apply any lotions this year, only spray
Twice each day, sunscreen will be re-applied. For those who are able, they will apply the sunscreen themselves. For those who need assistance, trained staff will assist them as needed.
Please check one of the following:*
- I authorize Fire Circle Staff to help apply sunscreen the family provides as indicated above. If my child forgets sunscreen, I give permission for NOAD Sunscreen to be used:
- I DO NOT authorize Fire Circle Staff to help apply sunscreen as indicated above. I understand that if my child forgets sunscreen, they will wait inside until I arrive with sunscreen I prefer my child to use.
Today’s Date & Brand of Sunscreen you are sending in with your child:
Name
First Last

Health History Signature:
I hereby certify that the above information given are true and correct as to the best of my knowledge.*
- I agree
Parent/Guardian Name*
Please enter Parent/Guardian Name signing this document. In this case a typed name is considered a signature
Date*
MM slash DD slash YYYY

Pearlstone The Associated

5425 Mt. Gilead Rd., Reisterstown, MD 21136
410-500-5417 | info@pearlstonecenter.org
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