Lowe Syndrome Conference Childcare

Conference Childcare Registration

Instructions: Please complete a childcare registration form for each of your children who will be participating in the childcare program at the conference. This includes boys with Lowe syndrome and their siblings. Thank you!

Parent/Guardian(Required)

First Last

Phone(Required)

Email(Required)

Child Name(Required)

First Last

Child Age(Required)

Date of Birth(Required)

Does this child have Lowe syndrome?(Required)

Does this individual have brothers or sisters who are also participating in the childcare program at the conference?

Please list their names

Are this individual’s immunizations up to date?

Does this individual have a history of seizures?

Please describe type and frequency of seizures and any special instructions for caregivers:

Does this individual wear glasses and or/contacts?

Please describe and provide any special instructions for caregivers::

Is this individual allergic to any food or other substances?

Please describe:

Please list any medications this individual is currently taking. (NOTE: CAREGIVERS WILL NOT ADMINISTER MEDICATIONS)

Please describe toileting procedures. (For example: Does the individual wear diapers? Can the individual use the toilet with or without assistance? Will the individual let you know when he/she needs to go?)

Please describe eating instructions and any food or drink restrictions. (For example: Can the individual feed him/herself? Drink from a cup? Can the individual have a snack such as juice and graham crackers?)

Please describe any behavior problems and instructions. (For example: If the individual has temper tantrums, what response do you suggest? Does the individual exhibit self injurious or aggressive behaviors?)

What a kind of activities does your individual enjoy the most? The least?

Please provide any other information that you would like us to be aware of