2022 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, 2022 to December 31st, 2022

Student Information:

Student's Name:

First NameMiddle NameLast Name

Birth Date:

MonthDayYear

Current Grade:

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

1st Emergency Contact's Name

First NameLast Name

Relationship to Student:

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

2nd Emergency Contact's Name

First NameLast Name

Relationship to Student:

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Medical Information

Medical Insurance Company

Policy #:

Physician:

First NameLast Name

Physician's Office Phone:

Area CodePhone Number

Dentist:

First NameLast Name

Dentist's Office Phone:

Area CodePhone 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)

Date of last tetanus shot:

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

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

Today's Date:

MonthDayYear

2022 Medical Form

MEDICAL HISTORY