Student Medical Information Form

Student Name

First

Middle

Last

Birth Date

Gender

Home Address

Street Address

Address Line 2

City/Town

State/Province

Postal/Zip Code

Parent/Guardian Name

First

Last

Home Phone

Work Phone

Mobile Phone

Email

Physician Name

Clinic Name

Phone Number

Clinic Address

Street Address

Address Line 2

City/Town

State/Province

Postal/Zip Code

Does your child have any illness ?

Please describe:

Does your child have any allergies?

Please describe:

Does your child have any disability?

Please describe:

Please list all medications that your child takes on a regular basis. Also, list the day and time that the medications are to be administered.

Please list at least two people as the emergency contact person.