2023-2024 Student Medical Information Form

Please complete this form in its entirety. DO NOT FORGET TO HIT THE SUBMIT BUTTON AFTER CLICKING LINK AT BOTTOM FOR VERIFIED ESIGNATURE.

Student's Name

Gender

Please select one option.

Male Female

Birthdate

Age

Please select one option.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Grade

Please select one option.

Pre-Kindergarten Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Graduated

Parent/Guardian Name

This address will receive a confirmation email

Phone

Address

Emergency Contact Name (1)

Emergency Contact Phone (1)

Emergency Contact Name (2)

Emergency Contact Phone (2)

Allergies, Medical, & Special Needs

Please select one option.

YES NO

Please list any allergies, dietary restrictions, medical or health problems that would affect his/her participation in any activities:

List any medications taken:

Name of child's physician and any other physician who can be consulted in the event of emergency or medical problems involving htis child when parent/guardian cannot be reached:

Physician Address

Physician Phone

Insurance Information

Name of Insurance Company

Insurance Address

Name of Primary Policy Holder

Policy Number

Phone Number of Insurance Company

Medical Release

***PLEAE BE SURE TO RETURN TO THIS PAGE AND HIT "SUBMIT" BUTTON TO FINALIZE SUBMISSION OF FORM***

Please use this link to esign medical release form (required for participation):

Click here to sign: eSignature for Medical Release

Description

Please complete this form in its entirety. DO NOT FORGET TO HIT THE SUBMIT BUTTON AFTER CLICKING LINK AT BOTTOM FOR VERIFIED ESIGNATURE.

2023-2024 Student Medical Information Form

Description

Please Fix the Following