Medical Form 2019-2020 - Al Manarat Heights

STUDENT'S INFORMATION

NAME OF THE STUDENT *

Date of Birth//

PARENT'S INFORMATION

NAME OF PARENT/GUARDIAN *

First

Last

HOME PHONE

WORK PHONE

IN CASE OF EMERGENCY

CONTACT PARENTS/PERSON NAME *

First

Last

HOME PHONE

WORK PHONE

NAME OF THE FAMILY DOCTOR *

First

Last

WORK PHONE

MEDICAL INFORMATION

HEALTH 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 *

YES
NO

PLEASE ATTACH UP TO DATE IMMUNIZATION RECORD *

C. Student is subject to:

D. Student wears contact lenses

E. Special Diet

F. Medications: I would like my child to be given,

Purpose of Medication

IN CASE OF EMERGENCY

In 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: *

Date *