NW Islamic School
Allergy & Medical Information Form
NW Islamic School takes the health and safety of every student seriously. This form collects essential medical and allergy information to ensure your child receives appropriate care while at school. Please complete this form thoroughly and update it whenever your child's medical information changes.
Student Information
Student's Full Name:
Grade:
Alberta Health Care Number:
Parent / Guardian Information
Primary Contact
Contact Name:
Relationship:
Phone Number (Home):
Format: (000) 000-0000.
Phone Number (Cell):
Format: (000) 000-0000.
Email Address:
example@example.com
Secondary Contact
Contact Name:
Phone Number:
Format: (000) 000-0000.
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Family Physician
Physician's Name:
Clinic / Hospital Name:
Phone Number:
Format: (000) 000-0000.
Allergies
Does your child have any known allergies?
Yes
No
If yes, please provide details below:
Allergy 1: Severity:
Mild
Moderate
Severe / Anaphylactic
Reaction Symptoms:
Allergy 2: Severity:
Mild
Moderate
Severe / Anaphylactic
Reaction Symptoms:
Allergy 3: Severity:
Mild
Moderate
Severe / Anaphylactic
Reaction Symptoms:
Does your child carry an EpiPen?
Yes
No
If yes: An EpiPen must be provided to the school office with clear labelling.
Does your child carry an inhaler?
Yes
No
Medical Conditions
Does your child have any of the following? (check all that apply)
Asthma
Diabetes
Epilepsy / Seizure Disorder
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Heart Condition
ADHD / ADD
Autism Spectrum Disorder
Hearing or Vision Impairment
Mobility Challenges
Other (please specify):
Please provide additional details about the condition(s):
Medications
Does your child require any medication to be kept at school?
Yes
No
If yes, please specify:
Dietary Restrictions
Does your child have any dietary restrictions?
Yes
No
If yes, please specify:
Emergency Action Plan
In the event of a medical emergency, I authorize NW Islamic School staff to:
Administer first aid
Administer EpiPen (if provided)
Call 911 / Emergency Medical Services
Transport my child to the nearest hospital /Preferred hospital (if any):
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Declaration & Signature
I confirm that the information provided is accurate and current. I agree to notify the school immediately of any changes to my child's medical or allergy information. I authorize the school to take necessary emergency action as indicated above.
Parent / Guardian Signature:
Date:
-
Month
-
Day
Year
Date
Print Name:
Office Use Only
Received by:
Date Received:
-
Month
-
Day
Year
Date
EpiPen / Inhaler on File:
Yes
No
N/A
Notes:
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