Health & Medical Contacts Form
Child's Last Name
*
Child"s First Name
*
Emergency Contact
Emergency Contact First Name (parent/legal guardian)
*
Emergency Contact Last Name (parent/legal guardian
*
Primary Telephone Number [E]
*
Alternate Telephone Number [E]
*
Email Address [E]
*
Texting Number [E]
Relationship to Child/Family
*
Would you like to add an additional Emergency Contact?
Please Select
yes
no
Emergency Contact 2 First Name
Emergency Contact 2 Last Name
Primary Telephone Number [E 2]
Alternate Telephone Number [E 2]
Email Address [E 2]
Texting Number [E 2]
Relationship to Child/Family [E 2]
Medical/Health Information
Please submit an up-to-date immunization record. Thank you.
Does your child have any food allergies (e.g., fruit, grains, dairy, etc.)?
*
Please Select
yes
no
Please identify whether these are airborn/contact/proximity or ingestion allergies.
*
airborn/contact (proximity)
ingestion only
No none food allergies.
Please list all food allergies, allergic reactions and whether the child carries medication in the event of a reaction. If your health care professional has provided you with a particular protocol, please provide this in writing under separate cover. Please note The Innovation Institute does not have health care professionals on site.
Does your child have any
medicine
allergies (e.g., penicillin, etc.)?
Medicine Allergies
*
Please Select
yes
no
No known medicine allergies
If you answered yes, please list all medicine allergies and allergic reactions, treatment protocols below.
Does your child have a latex allergy ?
*
Please Select
yes
no
Does your child have any other allergies that we should be aware of?
Please Select
yes
no
Please describe any other allergies your child has.
Does your child have ANY medical illnesses, diseases or conditions?
*
Please Select
yes
no
Please describe all medical illnesses, diseases, conditions and treatments below.
Does your child have ANY diagnosed or suspected mental or behavioral illnesses, diseases or conditions?
*
Please Select
yes
no
Please describe all mental or behavioral illnesses, diseases or conditions and whether your child is under treatment for them. Thank you.
Health Care Provider and Insurance
Name of Child's Primary Health Care Provider
*
Telephone Number
*
Street Address (One)
*
Street Address (Two)
City
*
State
*
Zip Code
*
Name of Insurance Provider
*
Primary Insurance Holder's Full Name (first and last)
*
Insurance Identification Number
*
Other Insurance ID Information
Acknowledgments
I certify that all information I have disclosed for the Health & Medical Contacts Form is complete and accurate. I agree to notify The Innovation Institute of any changes to the information provided as soon as I am aware of them. I understand that this information will only be used for medical emergencies and to provide guidance and relevant information to our staff and personnel.
*
yes
I understand that every attempt will be made to contact the emergency contact named on this form . I give permission to The Innovation Institute staff and personnel to arrange necessary related emergency medical transportation for my child names above on this form in the unlikely event of a medical emergency.
*
yes
In the event of an emergency, if a contact cannot be reached, I hereby give permission to The Innovation Institute to seek emergency medical treatment for my child named above on this form. I further authorize hospital physicians, medical personnel and related personnel to release relevant information concerning the medical status, medical condition, injuries, prognosis, diagnosis and related personally identifiable health information of my child named above on this form to The Innovation Institute staff and personnel.
*
yes
Authorized Signature
Today's Date
*
-
Month
-
Day
Year
Date
Print Full Name
*
Your primary email address
The Innovation Institute
288 Walnut Street, 300
Newtonville, MA 02460
617 340-9907
welcome@theinnovationinstitute.org
http://theinnovationinstitute.org
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