Family Information Notebook (FIN) - Vanderbilt Kennedy Center

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CHILD’S NAME: DATE OF BIRTH: 6 EMERGENCY CONTACT INFORMATION Contact Parent / Guardian: Name: Relationship: Daytime number: Cell phone: Other means of contact: Name: Relationship: Daytime number: Cell phone: Other means of contact: Other contact (Relative, neighbor): Name: Relationship: Daytime number: Cell phone: Other means of contact: Name: Relationship: Daytime number: Cell phone: Other means of contact: Electricity Company: Poison control: Gas Company: Security Company: __________________ Pediatrician’s emergency/after-hours contact number: ______________________ Preferred Hospital: __________________________________________________ Special Equipment/Medical Supplier: Company Phone Number ______________________________ _______________ ______________________________ _______________ COMMUNICATION AND WAYS TO COMMUNICATE DOES YOUR CHILD SPEAK? YES NO IS YOUR CHILD: VERBAL NON- VERBAL IS YOUR CHILD HEARING IMPAIRED: YES NO WHAT LANGUAGE DOES YOUR CHILD SPEAK? ENGLISH SPANISH OTHER IF OTHER, WHAT LANGUAGE/TYPE OF INTERPRETER? IS YOUR CHILD LEGALLY BLIND? YES NO Signature of Parent or Guardian Relationship to child Date
CHILD’S NAME: DATE OF BIRTH: CURRENT PHYSICIANS: 7 MEDICAL INFORMATION PRIMARY CARE PHYSICIAN: EMERGENCY PHONE: FAX: SPECIALTY PROVIDERS: EMERGENCY PHONE: FAX: SPECIALTY PROVIDERS: EMERGENCY PHONE: FAX: SPECIALTY PROVIDERS: EMERGENCY PHONE: FAX: SPECIALTY PROVIDERS: EMERGENCY PHONE: FAX: CURRENT PHARMACY: PHARMACY: PHONE NUMBER: CURRENT DIAGNOSIS AND CONDITIONS DATE RECEIVED DATE RECEIVED FAX: © Junior League <strong>Family</strong> Resource <strong>Center</strong> 2005
Page 1 and 2: 1 Family Information Notebook (FIN)
Page 3 and 4: 3 TABLE OF CONTENTS Emergency Healt
Page 5: 5 INTRODUCTION TO EMERGENCY HEALTH
Page 9 and 10: CHILD’S NAME: DATE OF BIRTH: 9 BA
Page 11 and 12: CHILD’S NAME: DATE OF BIRTH: 11 A
Page 13 and 14: 13 MEDICAL POWER OF ATTORNEY I, ___
Page 15 and 16: 15 Health and Development • Intro
Page 17 and 18: CHILD’S NAME: DATE OF BIRTH: 17 M
Page 19 and 20: Eye Exams 19 CHILD’S NAME: DATE O
Page 21 and 22: At home: 21 CHILD’S NAME: DATE OF
Page 23 and 24: 23 SUGGESTED INFORMATION TO INCLUDE
Page 25 and 26: 25 INTRODUCTION TO DAILY ROUTINE Th
Page 27 and 28: CHILD’S NAME: DATE OF BIRTH: 27 S
Page 29 and 30: 1. Equipment: Who provides (agency,
Page 31 and 32: CHILD’S NAME: DATE OF BIRTH: 31 M
Page 33 and 34: CHILD’S NAME: DATE OF BIRTH: 33 P
Page 35 and 36: CHILD’S NAME: DATE OF BIRTH: 35 T
Page 37 and 38: 37 INTRODUCTION TO EDUCATION / SCHO
Page 39 and 40: CHILD’S NAME: DATE OF BIRTH: Name
Page 41 and 42: Doctor Nurse Teacher CHILD’S NAME
Page 43 and 44: � TEIS Evaluations and ISPs � C
Page 45 and 46: INTRODUCTION TO RESOURCES / OPTIONA
Page 47 and 48: Your Child’s Educational Rights:
Page 49 and 50: 49 Kay Flowers, Complaints Consulta
Page 51 and 52: 51 State Special Schools Tennessee
Page 53 and 54: 53 TENNESSEE DEPARTMENT OF CHILDREN
Page 55 and 56: 55 ADDITIONAL EDUCATION AND HEALTH
Page 57 and 58:
57 SPECIAL EDUCATION MEDIATION REQU
Page 59 and 60:
DUE PROCESS HEARING REQUEST FORM TE
Page 61 and 62:
61 INTRODUCTION TO APPENDICES SECTI
Page 63 and 64:
Physical Therapist (PT): a licensed
Page 65 and 66:
QUALITY HEALTH CARE • There are s
Page 67 and 68:
67 Month: _________________________
Page 69 and 70:
F Page Family Resource Center Conta
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