Medical Information

Child's Name *

First

Last

Medical Information

Child's Primary Care Provider *

Phone *

Medical Insurance

Date of Last Exam *

Preferred Hospital *

Child's Dentist *

Phone *

Dental Insurance

Date of Last Exam *

Allergies and Medical Conditions: Please describe below any health issues of which the staff should be aware. Include any food or other allergies (including insect stings); medical conditions (e.g., asthma); medications prescribed, vision or hearing loss; a history of convulsions or any accidents/illnesses that might affect your child’s participation in activities. If any conditions are indicated here, we will be in touch to create individual plans for the school year.

Any dietary preferences we should be aware of:

Medical Information

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