Emergency Contact And Release From School Information (Page 2 of 4) in pdf

Health History/Student Information

Student Name:___________________________________ Date of Birth:_______________________ Gender:__________________________

1) Does your child have any known allergies?

[ ] Y

[ ] N

If yes, list here: __________________________________________________________________________________________________

_______________________________________________________________________________________________________________

2) Please list any special dietary or medical information necessary for management in case of an emergency:

_______________________________________________________________________________________________________________

3) Does your child exhibit any of the following symptoms (circle all that apply)?

Afraid of new tasks/situations

Constantly moving

Loses temper easily

Negative attitude

Bullying

Facial tics

Stubbornness

Nail biting

4) At what age did your child (please fill in the ages or “N/A” if your child hasn’t performed the task as of yet):

Become toilet-trained

Say words

Say sentences

Crawl

Walk

Tie his/her shoes

Stop drinking from a bottle

Ride a bike

5) Please describe your child’s “everyday habits” in the following areas:

Eating _________________________________________________________________________________________________________

Sleeping________________________________________________________________________________________________________

6) Applicants with a disability who would like to request accommodations should identify themselves early in the application process.

Documentation from a qualified professional is required and should either be enclosed with this application or sent directly to

the Admissions Office. Auxiliary aides and services may be available on request, possibly at parent expense, if the applicant has a

disability and would like to request accommodation in the admission process. Please explain here (and provide documentation):

_______________________________________________________________________________________________________________

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An Investment in Your Child’s Future!

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