Parent/Guardian Information
Medical Insurance Information
Medical History Information
To be completed by parent or legal guardian.
Please check "YES" or "No" and provide details where requested. All information will be kept CONFIDENTIAL.
Are you allergic to any medication (including aspirin, penicillin, sulfa, etc.)?
Do you take any prescribed medications on a permanent or semi-permanent basis.
Have you ever been told by a doctor that you were anemic?
Have you ever been told by a doctor that you have sickle cell anemia?
Do you have or have you had high blood pressure?
Do you have or have you had heart disease?
Do you have or have you had lung disease?
Do you have or have you had kidney disease?
Do you have or have you had liver disease?
Have you ever been told by a doctor that you have asthma?
Have you ever had a hernia or "rupture?"
If yes, has the hernia or "rupture been repaired?"
Have you been "knocked out" (unconscious) in the past three years?
Have you had a concussion or other head injury in the past three years?
Have you ever been hospitalized overnight due to a head injury?
Is/Are there any special accommodation(s) needed?
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