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Medical Information Form
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Medical Information Form
Your Name
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MEDICAL INFORMATION
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HEALTH INFORMATION
Does your child suffer from any allergy or health condition
*
Yes
No
If your answer is yes please give full details below
Symptoms following exposure
General precautions to prevent an emergency
REQUIRED TREATMENT & MEDICATION
1. Does your child require immediate medication
( if so please provide medication to be left with staff in the case it is required to be administered)
2. Can your child self administer medication
3. If your answer to question 2 is no do you give the Principal or a staff member permission to administer medication that you have provided
Please give details of required medication & treatment
I
authorize for a ambulance to be called in the case of an emergency, all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Child Photo
For life threatening allergies or health conditions where immediate treatment or medication is required to be administered a current photo of the child is required.
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