TY Health Form
It is VITAL all students/parents/guardians return this form. Information on this form is private and confidential.
Name of Student:
First Name
Last Name
Student's Date of Birth:
-
Month
-
Day
Year
Date
Student E-mail:
example@example.com
Name of Parent/Guardian:
First Name
Last Name
Parents/Guardians E-mail:
example@example.com
Parents/Guardian's Mobile Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
Providence
Eircode
Full name of Doctor/GP:
First Name
Last Name
Address of GP:
Street Address
Street Address Line 2
City
Province
Eircode
GP's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
1. Does your son have Asthma?
Yes
No
2. Does your son require the use of an inhaler?
Yes
No
3. Does your son have an allergy?
Yes
No
4. If yes, please give details below. (including whether your son requires the use of Epipen or equivalent.
5. Can your son swim? (Please note activities that require swimming will generally require the wearing of a life jacket or equivalent).
Yes
No
6. How many metres can your son swim?
less than 10 metres
up to 10 metres
more than 10 metres
7. Please disclose any other relevant healthcare issues in this section not outlined above.
8. Does your child have any special eating requirements? (e.g. halal, vegetarian, vegan etc)
Submit
Should be Empty: