Title HEALTH AND MEDICAL FORM.pdf ✅

Health or Medical Form Name of Child: Birthday: Male Female Address: Parent/Guardian: Working Mobile Phone: ____________ Health/Medical History Informed Consent The disclosure of student health information within the school is limited to the information necessary to serve the student’s health or educational interest. Your signature gives permission for the staff to provide precautions and procedures to protect your child in the classroom and to foster academic success. Your signature is an informed consent to share this health history information with school staff on a need-to-know basis for academic success and emergency plans. X ________________________ ________________ ________________ Parent/guardian signature Working Mobile Phone Date Health Problem/Concern: Please explain about any health problem that your child has now ____________________________________________________________________________________ Yes No Is your child now under regular medical care for any conditions? If yes, what is the condition? ______ Yes No Does your child have allergies that could be a problem at school (foods, pet, insects)? If yes, please list: ______ Has your child experienced any of the following? asthma seizure diabetes speech problem respiratory disorder digestive problem kidney disease heart condition serious illness serious accident surgery head injury hospitalization other (explain)