Medical Form Please enable JavaScript in your browser to complete this form.STUDENT'S INFORMATIONNAME OF THE STUDENT *Date of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PARENT'S INFORMATIONNAME OF PARENT/GUARDIAN *FirstLastHOME PHONEWORK PHONEIN CASE OF EMERGENCYCONTACT PARENTS/PERSON NAME *FirstLastHOME PHONEWORK PHONENAME OF THE FAMILY DOCTOR *FirstLastWORK PHONEMEDICAL INFORMATIONHEALTH CARD NUMBER:MEDICAL INSURANCE PLAN NO.A. Please note any health problem, physical handicap, emotional difficulty, behavioural problem, or facts which may limit full participation in the classroom.B. Student’s immunization shots are current, i.e. tetanus and diphtheria, typhoid, smallpox, and polio vaccine *YESNOPLEASE ATTACH UP TO DATE IMMUNIZATION RECORD * Click or drag a file to this area to upload. C. Student is subject to:asthmasensitive skinsleepwalkingnosebleedear achesinus troubleconvulsionshigh blood pressurefaintingfrequent coldsheadachemotion sicknesstonsillitisnightmaresbed wettingallergies (describe)eye infectionbronchitiskidney problemD. Student wears contact lensesStudent wears contact lensesYesNoE. Special DietF. Medications: I would like my child to be given,Purpose of MedicationIN CASE OF EMERGENCYIn case of emergency, I hereby give permission to the physician selected by the school or transport my child to a nearby emergency medical facility to provide necessary treatment for my child. I understand that minor injuries or accidents will be treated on the school premises and that I will be notified of any such treatment. In compliance with state regulations, I will pick-up my child as soon as possible in the event that Al-Manarat Heights calls to inform me that my child is ill. Checkboxes *I agree to inform Al-Manarat Heights immediately of communicable illnesses any of my family members contract even if they do not attend Al-Manarat Heights.Parent/Guardian signature: *Clear SignatureDate *EmailSubmit