School District No.48 (Howe Sound)
Medical Information Sheet
To be completed by parent or guardian
Please answer the questions below as accurately as possible. This is important
in order to have all necessary information in case of an emergency. None of the
information will be used to “screen out “ participants. Please be truthful.
It is your responsibility to notify us if any of the following information is
changed and/or inaccurate.
Student Information
Participant Name:__________________________________________________
Address:__________________________________ Phone Number:(__)_______
Care Card Number:_________________________ Date of Birth:____________
Gender:______________ Height: ________ Weight: _________
Family Physician: __________________________ Phone Number: (__)______
Place of Practice:__________________________________________________
Date of last tetanus inoculation?________________________
Parent Information
Mother: ________________________ Father:_________________________
Address:_______________________ Address:________________________
Home Phone #:__________________ Home Phone #:__________________
Work Phone #: __________________ Work Phone #: __________________
Cellular #: _____________________ Cellular #: _____________________
address same as student address same as student
In case of an emergency, please call:
1. Name:_________________________________ Relation: ________________
Phone Number: (home)___________________ (work)___________________
2. Name:_________________________________ Relation: ________________
Phone Number: (home)___________________ (work)___________________
Medical Information
Are there any past injuries or disabilities that the leader should be aware of?
(Knees, back, concussion, etc…) If so, please explain. Yes___ No___
________________________________________________________________
________________________________________________________________
________________________________________________________________
Does the student have a medical condition? (Diabetes, etc…) If so, please
describe. Yes___ No___
________________________________________________________________
________________________________________________________________
________________________________________________________________
Does student have serious allergies? (To foods, drugs, etc…) Yes___ No___
If yes, describe. Do you carry an EpiPen, or other allergy treatment?
________________________________________________________________
________________________________________________________________
Is the student afraid of heights or have any other phobias? Yes ___ No ___
If yes, please explain _______________________________________________
________________________________________________________________
________________________________________________________________
Does your child have special dietary restrictions? Yes ___ No ___
If yes, please explain _______________________________________________
________________________________________________________________
________________________________________________________________
Does the student wear Glasses? Yes___ No___
Contact Lenses? Yes ___ No____
Both? Yes ___ No ___
Medications:
Is the student currently on any medication? Yes___ No___
If you would like your child to be given any medication, please complete the
following:
Name of medication ____________________________________
Condition for which the drug is being taken: _____________________________
How it is to be given: __________________ Quantity to be given: ___________
Times to be given: ____________________________
Medicine should be clearly labeled with the child’s name, name of medication,
what it is to be used for, quantity to be given and times.
In case of emergency, I hereby give permission to the physician named above,
or, in his absence, to any other physician, to provide treatment to my child.
We have completed this medical form, accurately, and truthfully, to the best of
our knowledge. We understand that any injury or illness that is aggravated by, or
a result of the student’s participation in this program and any evacuation cost
arising thereof, is solely our own responsibility and we hereby release
____________________ Secondary School and School District 48, and its
employees from any future claims we might make against them. We understand
that it is our responsibility to inform the instructors before the any field trips, of
any changes affecting the student’s health, that may have arisen after filling out
this form.
Student Signature: _________________________ Date:_________________
Parent/Guardian: __________________________ Date:_________________
For school use only:
Verified by : ____________________________
Date: _____________________________