S3.amazonaws.com
[pic] NYC Middle School Basketball League
MEDICAL/HEALTH FORM-2019/20 SEASON
(TO BE COMPLETED BY A PARENT OR GUARDIAN IN PEN ONLY)
THIS CONFIDENTIAL HEALTH RECORD WILL ONLY BE USED TO ENSURE THE SAFETY OF THE CHILDREN
Student’s Name______________________________ Date of Birth_________________
1. Please provide your child’s medical history:
CONDITION YES (if yes, write NO ALLERGY YES NO
approximate date)
ASTHMA ________ ______ PENICILLIN _____ _____
EAR INFECTIONS ________ ______ INSECT STINGS _____ ______
CONVULSIONS ________ ______ FOODS _____ ______
DIABETES ________ ______ PLANTS _____ ______
CHICKEN POX ________ ______ HAY FEVER _____ ______
MEASLES ________ ______ If yes to any of the above, please
GERMAN MEASLES ________ _______ specify___________________________
RHEUMATIC FEVER ________ _______ _________________________________
MUMPS ________ _______ _________________________________
GLASSES ________ _______ _________________________________
Has your child been ALLERGIES NOT MENTIONED:
exposed to any communicable _________________________________
diseases in the last three weeks? YES_____ NO_____ _________________________________
If YES, to what?_________________________________
Please explain any chronic or recurrent illness/disorder not mentioned above, or conditions that could result in
an emergency:___________________________________________________________________________
______________________________________________________________________________________
2. List significant illnesses or surgeries. Provide 3. Special situations or needs that program staff
the date and any instructions. should be aware of:
_____________________________________ Child has behavioral difficulties__________
_____________________________________ Child has emotional disabilities__________
_____________________________________ Other______________________________
4. Medication
Does your child take medications for any condition? YES_____ NO_____ If yes, describe the condition. If your
child needs medication during the after-school, please ask the Director for a Medication Authorization form.
__________________________________________________________________________________________
5. Activities to be encouraged: 6. Activities your child cannot participate in:
_____________________________________ ______________________________________________
7. My child may participate in all program activities, except those noted in number 6 above.
Parent’s Signature_______________________________________ Date_______________________
Parent’s Email Address (Print)_________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
Related searches
- getroman com reviews
- acurafinancialservices.com account management
- acurafinancialservices.com account ma
- getroman.com tv
- http cashier.95516.com bing
- http cashier.95516.com bingprivacy notice.pdf
- connected mcgraw hill com lausd
- education.com games play
- rushmorelm.com one time payment
- assistant s3 duty description oer
- ysq s3 test
- ysq s3 interpretation