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•Medical Form•
Child’s Name, Birth date
Allergies, Needs, etc.
Parent’s Name(s)
Address
Home Phone Number(s)
Cell or pager number
Doctor’s Name (PCP)
Doctor’s Address
Doctor’s Phone
Medical History
Surgeries
Current Medications
(and dosage)
Kids’ Coop Cambridge • St. James Episcopal Church • 1991 Massachusetts Avenue• Cambridge,
MA 02140 info@kidscoopcambridge.com • www.kidscoopcambridge.com • 617.868.9079 • Hours:
M-F, 9am to Noon
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Child’s Name: _______________________________________
Child’s Date of Birth: _______________________________
Please list emergency contacts and each adult that has permission to pick up your child (do not list Coop
parents, they are assumed allowable caregivers). Please notify the caregivers on duty if you have someone
new picking up. Please ask this person to have a photo id ready to present to caregivers. Notify the Coop if
there is anyone in your life who many NOT have permission, but who may show up to try to take your child.
Name and Address Relationship to child Phone
1
2
3
4
For your child’s safety, please keep the Coop’s phone number with you at all times while your child is at Coop.
If for any reason we need to contact you, we need to have the correct number for where you will be. Please
keep all your Coop medical records up to date with contact information. The emergency room asks for medical
history, medicine allergies, and past surgeries. Please ask your doctor if you are not sure what to include for
emergency care instructions.
Coop is located in the St. James Episcopal Church at 1991 Massachusetts Avenue, Cambridge MA 02140-
1306. The phone is (617) 229-8008 (hours M-F, 9am to noon only).
This is a parents’ cooperative and not a professional day care. We are not licensed nor are we regulated by
any agency. Caregivers are encouraged, but not required to know first aid and other safety methods. We care
for each others’ children in a loving, family atmosphere. It is against Coop policy to strike or physically punish a
child. Children having a hard time at Coop are comforted and talked with, but a parent will be called: after 15
minutes of hard, inconsolable crying, if the child is hitting or endangering themselves or other children, or does
not have proper clothes after a spill or bathroom accident.
x
Parents Signature for Emergency Medical Care
Last updated 10/18/07 (SSS)
Kids’ Coop Cambridge • St. James Episcopal Church • 1991 Massachusetts Avenue• Cambridge,
MA 02140 info@kidscoopcambridge.com • www.kidscoopcambridge.com • 617.229.8008 • Hours:
M-F, 9am to Noon