INSTRUCTIONS TO PARENTS/GUARDIANS:
(1) Complete all items on this form. Sign and date where indicated. Please mark “N/A” if an item is not applicable.
(2) If your child has a medical condition which might require emergency medical care, complete Page 2 of this form. If necessary, have your child’s
health practitioner review that information.
NOTE: THIS ENTIRE FORM MUST BE UPDATED ANNUALLY.