Student Health and Contact Information
Student Health Record and Contact Information Form
This Health History is a required form. This information is part of the acceptance process. It is gathered to assist us in identifying needed care and support. Please fill in all information as completely as possible and check appropriate spaces.
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Name
First Name
Last Name
Type a question
Male
Female
Overall Health
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Chronic/Recurring Illness and/or Convulsive Disorder (list):
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Current Infections (list):
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Physical Limitations (list):
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Allergies (list):
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Family Physician
Physician's phone number
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Do you have health insurance?
Yes
No
If you answered Yes to Health Insurance, please provide the Insurance company name, policy number and group number (if applicable). Please note that lack of insurance does NOT determine acceptance to our program.
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Family Dentist
Dentist Phone Number
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Prescription Medications (you will have the opportunity to update this list when you bring your child to the training). List Medications and the dosage:
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Are all immunizations up to date? (Immunizations must be up to date before the student is accepted into the program)
Yes
No
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Parent/Guardian #1 Name
Phone number
Email address
Parent/Guardian #2 Name
Phone Number
Email Address
Emergency Contact phone number for daytime
Emergency Contact phone number for nighttime
Email address
If the emergency contact(s) are NOT one of the Parent/Guardians listed above, please enter their name(s) here:
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Should be Empty: