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Daycare Medical Form — Free Digital Template
This is a daycare medical form as one online form: known allergies with the reaction and what staff should do, daily and as-needed medications, chronic conditions, dietary restrictions, the child’s physician, an upload slot for a care or action plan, and signed consent for emergency treatment. Parents fill it in on a phone. Free, and every field is editable before you send it.
No credit card. Every field is editable once it is in your account.
Last updated September 5, 2026
Enrollment packet — preview
6 sections · 29 fields · nothing here is submitted
Child and physician
Child's full name (required)
Date of birth (required)
Primary care provider — name and practice (required)
Primary care provider — phone (required)
Preferred hospital
Health insurance carrier and member number
Allergies
Does the child have any known allergies? (required)
- No
- Yes
Allergen(s)
Food, medication, insect sting, latex, environmental.
Reaction the child has had
What staff should do
Avoidance steps, and what to do if exposed.
Does the child carry an epinephrine auto-injector?
- No
- Yes
Upload allergy action plan (if any)
Medications
Daily medications (name, dose, time given at home)
Medications to be given at the program (name, dose, time)
Prescription medication must be in the pharmacy-labeled container.
As-needed medications and when to give them
Over-the-counter medications the program may give with a phone call
Conditions and special care
Chronic conditions (asthma, seizures, diabetes, heart, other)
Signs staff should watch for and what to do
Dietary restrictions or special feeding instructions
Physical, developmental, or behavioral needs staff should plan for
Upload care plan, action plan, or physician instructions (if any)
Health history
Immunizations are up to date for the child’s age (required)
- Yes
- No
- Exemption on file
Date of most recent well-child visit
Hospitalizations, surgeries, or serious illnesses
Anything else the program should know
Authorizations
I authorize the program to administer the medications listed above as described
I authorize emergency medical treatment if a parent cannot be reached (required)
Parent or guardian signature (required)
Date signed (required)
What's inside, and why each part is there
Requirements vary by state — check your state's licensing requirements before you send this to a family.
01 · Child and physician
Every medical question on this form is useless without the name of the doctor who can answer the next one. Physician and preferred hospital come first.
02 · Allergies
Asking for the reaction and the response separately is what turns “peanut allergy” into something a substitute can act on. Severe allergies also need an action plan on file and, where prescribed, the auto-injector on site.
03 · Medications
Most states require written parental authorization before staff give any medication, prescription or over-the-counter, and a log of each dose. This section records what the child takes; the authorization is signed at the end.
04 · Conditions and special care
Asthma, seizures, diabetes, and feeding issues each need a specific response from whoever is with the child. A care plan from the doctor is the document licensing expects to see for a chronic condition.
05 · Health history
The immunization record itself is a separate document with its own form; this is where the parent tells you its status and where the child was last seen, so you know what to chase.
06 · Authorizations
Two signatures do the work here: authorization to give the medications listed above, and consent for emergency treatment. Each is its own decision, so each has its own line.
Common questions
Is a daycare medical form the same as the health exam?
No. The health exam (a physical) is completed by a physician on your state’s form and has its own deadline after enrollment. This medical form is the parent’s account of allergies, medications, and conditions — the information staff act on day to day. Keep both in the child’s file.
Can staff give medication based on this form alone?
Usually not. Most states require a separate written authorization for each medication with the name, dose, and times, plus a log of each dose given. This form collects the information and includes an authorization line; check your state’s medication rule for what it must contain.
What if the child has no allergies or conditions?
The form still matters: the “No” answers, the physician, and the emergency consent are what an ER and your staff need. Optional fields can be left blank; required ones are only the identifying details, the physician, and the consent.
How do parents attach a care plan?
The form has file-upload fields. A parent takes a photo of the plan with their phone and it attaches to the submission and lands in the child’s file.
The AI builds this packet into your account, ready to edit and send.
Informational template — enrollment requirements vary by state; not legal advice. Check your state's licensing requirements for what your program must collect.