YES Winter 2020 Health Form
Student's First Name
*
Student's Last Name
*
Parent/Guardian 1 Name
*
First
Last
Parent/Guardian 1 Cell Phone
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Parent/Guardian 2 Name
First
Last
Parent/Guardian 2 Cell Phone
-
Area Code
Phone Number
Emergency Contact (Must be different than parent(s)/guardian(s) listed above)
*
First Name
Last Name
Emergency Contact Cell Phone
*
-
Area Code
Phone Number
Please list all known allergies.
*
ADD/ADHD
*
yes
no
Anxiety or Depression
*
yes
no
Asthma
*
yes
no
Diabetes
*
yes
no
Headaches, Migraines
*
yes
no
Heart Defect/Disease
*
yes
no
Kidney Disease
*
yes
no
Muscular or Skeletal Disorder
*
yes
no
Is student taking any prescription medications? Indicate EpiPen or inhaler use.
*
Explain any specific needs or accommodations for any known behavioral, physical, emotional and/or educational challenges:
*
Are all immunizations current?
*
yes
no
Physician
Physician's Phone Number
-
Area Code
Phone Number
Preferred Medical Facility
Use of Photographs
*
I permit my child's picture to be used by MITY
I DO NOT permit my child's picture to be used by MITY
Parent/Guardian Signature
*
First and Last Name
Today's Date
*
-
Month
-
Day
Year
Date
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Submit
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