Supplemental Health Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian Name
First Name
Last Name
Best Emergency Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Allergies - Please be as specific as possible. List allergies, their severity, and the recommended action after exposure to allergen:
Does your child carry an Epi-Pen?
Other Medical Issues: Please be specific as possible, and include needed accommodations and/or the recommended response to a medical episode.
Name of Child's Primary Physician
Physician's Phone Number
I understand that in the event of a serious accident or medical emergency, a staff person or his/herdelegate will call “911” and attempt to contact the child’s parent. The above medical information will beshared with the appropriate emergency personnel. I agree to assume financial responsibility for any emergency response, treatment, transport or medication administered by the appropriate emergency personnel.
I understand
Signature
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: