Ybarra's Little Helpers
Parent Allergy & Care Information Sheet
Please fill this out on paper before drop-off and review important details directly with the caregiver. This form is not submitted online.
Child's name
Date of birth
Parent / guardian name
Parent / guardian phone
Emergency contact name
Emergency contact phone
Allergy & medication details
Allergies, sensitivities, and triggers (food, medication, environmental, or other)
Symptoms to watch for
Medications and exact parent-provided instructions
Dietary restrictions or food notes
Ybarra's Little Helpers
More care details
Use the space below for anything that helps your child feel safe, comfortable, and understood.
Medical conditions, comfort needs, routines, or other important notes
Pediatrician / clinic (optional)
Pediatrician / clinic phone (optional)
Authorized pickup people (full name and phone number)
Parent / guardian signature
Date
Parent / guardian reminder: Please supply any needed medication, keep it current, and provide accurate, up-to-date information. This family-provided sheet does not replace a medical care plan or emergency instructions from your child's healthcare provider.