Medical Form 2024 to be completed by all new Somersfield students

Student Name*
Date of Birth*

MonthDayYear
Date
School*
Class*
Parent/Guardian*
Address*
Contact Telephone No.s*
Email*
example@example.com

Child Health History

	NO	YES	Comments
ADHD
Allergies
Asthma
Birth Defects
Bladder/Bowel Problems
Blood Disorders
Bone/Joint Disorders
Developmental Delays
Learning Problems
Diabetes
Ear/Hearing Problems
Vision Problems
Emotional Problems
Heart Problems
Seizures
Nutritional Problems

Current Medications Required at School*
Physician*
Emergency Contact*
Parentguardian signature*

Clear
Date*

MonthDayYear
Date
Privacy Statement: This form is confidential and will only be used by key personnel for the safety of the student.

Child Health

67 Victoria Street, Hamilton P.O. Box HM 1195, Hamilton HM EX,

Bermuda Fax: (+1 441) 292-4420
Should be Empty: