Health and Medical Information
Complete one form per child attending:
Child’s Name_______________________________ Date of Birth ______________
Address ___________________________________ Grade________ M/F________
City_______________________________________ State _______ Zip__________
Parent/Guardian_______________________________________________________
Home Phone ____________________ Work Phone___________________________
Cell Phone/s_____________________ Email Address_____ ___________________
Emergency Contact:
___________________________________Contact Phone______________________
Medical History
Doctor ______________________________ Phone ___________________________
Address______________________________ State _______________ Zip__________
Insurance_____________________________ Policy Number ____________________
Please write and ALLERGIES your child may have in the appropriate column:
FOOD ALLERGIES | MEDICINAL ALLERGIES | ENVIRONMENTAL ALLERGIES |
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DOES CHILD REQUIRE ADMINISTRATION OF MEDICATION? Yes____ No____
(If “Yes”, fill out the form that says Medical Dispensation)
Please write the LAST IMMUNIZATION DATE from the following conditions:
Tetanus | Mumps | Small Pox | Measles |
Rubella | Polio | Whooping Cough | Diphtheria |
