Annual Medical Information Form printable pdf download

ANNUAL MEDICAL INFORMATION FORM

Child’s Name______________________________________________________________________________________

Address____________________________________________________City,State______________________________Zip_________

Sex ____________________________Date of Birth ____________________________________Age _______ Grade _____________

School ______________________________________________________________________________________________________

Doctor’s Name____________________________________________________________ Phone Number________________________

Father/Guardian’s full name:____________________________________________________________________________________

Home Phone :_______________________________________ Cell Phone ______________________________________________

Home address:________________________________________________________________________________________________

Place of business/address:___________________________________________________ Phone : ___________________________

Mother/Guardian’s full name:____________________________________________________________________________________

Home Phone:________________________________________ Cell Phone ______________________________________________

Home address:________________________________________________________________________________________________

Place of business/address:___________________________________________________ Phone :____________________________

Relative or friend to contact if unable to reach parent/guardian in the event of emergency:

Name & Relationship:__________________________________________________________________________________________

Phone _____________________________________________________________________________________________________

Insurance Carrier:_____________________________________________________________________________________________

Insurance Policy Number:______________________________________________________________________________________

Insurance is provided by which parent and/or place of employment? ____________________________________________________

Address and Phone Number of Company:__________________________________________________________________________

MEDICATIONS: (EITHER A PHYSICIAN’S PRESCRIPTION OR A PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS.

PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM.) My child is taking the following medication(s):

Description ________________________________________________________________Dosage___________________________

I hereby grant permission for non-prescription medications to be given, if deemed appropriate.

Drug Allergies: ______________________________________________________________________________________________

Other Allergies (food, plants, insects, etc.): ________________________________________________________________________

Other known diseases, disorders, or disabilities: ____________________________________________________________________

Revised 8/2007

Annual Medical Information Form

Annual Medical Information Form