Student Health Information Form


Student Information

First Name

Last Name


Date of Birth

Gender


Grade

School Year


Father/Guardian Information

First Name

Last Name


Home Phone

Work Phone


Mobile Phone

Email


Address Line 1

Address Line 2


City/Town

State/Province

Postal/Zip Code


Mother/Guardian Information

First Name

Last Name


Home Phone

Work Phone


Mobile Phone

Email


Address Line 1

Address Line 2


City/Town

State/Province

Postal/Zip Code


Emergency Contact Person Information

Please list the emergency contact persons other than parent/guardian.

First Name

Last Name

Contact Phone

Relationship to Student

1
 
 
 
 
2
 
 
 
 
3
 
 
 
 

Health Information

Please tick if the student suffer from any following conditions.


Medication Information

Please list all medications that the student is currently taking.

Medication Name

Dose

Reason

1
 
 
 
2
 
 
 
3
 
 
 
4
 
 
 
5
 
 
 
6
 
 
 
7
 
 
 
8
 
 
 
9
 
 
 
10
 
 
 


Parent/Guardian Authorization

Parent/Guardian Signature


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