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.

Google Online Preview   Download