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Medical Information

 
Family Name: Given Name:  
Age: Gender: Female   Male Date of Birth:
   
Address:
City: Province/State:
Postal/Zip Code:    
Telephone: Fax Number:
E-mail: Cell Number:
       
1. Does your child have any of the following medical conditions which will require special care?
Severe Asthma
Seizure/epilepsy
Diabetes
Other - please specify: 		 
 
2. Is he/she on any medication? If yes, please specify:
       
3. Does your child have any life threatening or non-life threatening allergies? If yes, please specify:
 
4. Please indicate any additional health issues that the group leaders should be aware of.
 
5. Please indicate any special food requirements.
 
How did you hear about our programs?
 
Authorization:
 
Name of parent/guardian (as a sign of agreement):
Date:
   

 
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