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Exceptional Sitters

(One form must be completed for each child in care)

Child's Full Name:
Home Address:
City/Town:
Postal Code:
Date of Birth :
Health Card#:
Phone:
Language(s) Spoken at Home:
Others in Household:

Doctor's Name:
Address:
City/Town:
Postal Code:
Phone:

Mother's Name
Address: (if not same as child)
City/Town:
Postal Code:
Home Phone:
Work Phone:
Cellular/Pager:

Father's Name
Address: (if not same as child)
City/Town:
Postal Code:
Home Phone:
Work Phone:
Cellular/Pager:

Legal Custody of Child:	Together Mother Father Joint
Parent's Relation to Child:	Biological Adoptive Foster Joint
Family Marital Status:	Separated Divorced Single Joint

Does your child have a specific diagnosis or condition, please name or explain:
Has your child had any significant medical intervention? Please explain:
Is your child currently taking any medication(s)? Please explain: Note: If exl will be administering medications(s), a separate Authorization to Administer Medications form must be completed.
Allergies (Foods, Environmental, Other):
Mobility Limitations:
Additional Information:
Anticipated Sitters Needs:
Comments: