West Hants Wellness Clinics Registration Form (registration begins in the Spring of 2009)

What school will your child attend in September 2011?

Child's Name

Last Middle First

Previous Names (if any)

Date of Birth   Sex Male Female

Parent/Guardian(s)

Home Phone #

Alternative Phone # 

Street Address 

Mailing Address 

Town   Postal Code

Family Doctor

Does your child have any current medical problems?   Yes No

If so, please explain

Does your child have any allergies? Yes No

If so, please explain

Has your child been to a professional for any of the following?

Vision                                            Hearing       

Dental                                            Behavior

Speech                                         Development

Are there any issues relevant to your child's development that you would like to see more information on? Any questions or concerns?

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