First Name
Last Name
Date of Birth
Grade
Is your child allergic to any medications?
If yes, please enter:
Medication Name | Reaction | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Does your child have any food allergies?
If yes, please enter:
Food to avoid | Reaction | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 |
Is your child allergic to bee sting?
If yes, please list all the required medications.
Is your child allergic to fire ant?
If yes, please list all the required medications.
Does your child have special diet requirements?
If yes, please explain:
Does your child have asthma?
If yes, please list all the required medications.
Is your child diabetic?
If yes, please list all the required medications.
Does your child have glasses?
Does your child have a hearing problem or use an assistive hearing device?
Declaration
I hereby declare that the information I have provided in this application is true and correct to my best knowledge.
Parent/Guardian Signature
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