Medical Information

Child's Name *

First

Last

Medical Information

Child's Primary Care Provider *

below aware vision

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/food preferences or avoidances we should be aware of:

Medical Information

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