2019 Medical Form

*PLEASE NOTE - If medical information is the same as what you filled out last year, simply fill out the student's name and click submit form.

Form effective dates: January 1st, 2019 to December 31st, 2019

Student Information:

Student's Name:

First Name Middle Name Last Name

Birth Date:

Month Day Year

Current Grade:

7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Grade

Gender

Male Female

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

- Area Code Phone Number

Cell Number

- Area Code Phone Number

E-mail

Emergency Information

1st Emergency Contact's Name

First Name Last Name

Relationship to Student:

Phone Number

- Area Code Phone Number

Alt. Phone Number

- Area Code Phone Number

2nd Emergency Contact's Name

First Name Last Name

Relationship to Student:

Phone Number

- Area Code Phone Number

Alt. Phone Number

- Area Code Phone Number

Medical Information

Medical Insurance Company

Policy #:

Physician:

First Name Last Name

Physician's Office Phone:

- Area Code Phone Number

Dentist:

First Name Last Name

Dentist's Office Phone:

- Area Code Phone Number

List any allergies

Do you suffer from, or have ever experienced, or are being treated currently for any of the following: (Check all that apply)

asthma frequent upset stomach epilepsy/seizure disorder physical handicap heart trouble diabetes

Date of last tetanus shot:

Do you wear any of the following? (Check all that apply)

glasses contact lenses dentures defibrillator (left) defibrillator (right) hearing aids (left) hearing aids (right)

Please list and explain any major illnesses you have experienced during the last year:

Please list any medication and dosages:

In the box below, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.

Answer here:

Parent Signature *

Clear

Today's Date: *

- Month - Day Year

2019 Medical Form

MEDICAL HISTORY