Student Health Form
Please fill out one Student health form per student (returning students only need to fill out if there are changes)
Please Enter Student's Full Name
What Grade will your Student Be entering?
Please Select a Grade
After School Only
Please List Any Medical Treatment your Child is currently under
Please include psychiatric and physical treatment reply N/A if none
Please list any medications that your child takes on a regular basis
Please List Name of Medication, Dosage, times taken, and reason please enter N/A if none
Is your Student Right or Left Handed
Does your Student wear vision correction?
Please answer if your student wears any vision correction such as glasses
Does your child have normal hearing
No- But Corrected with Hearing Aid
Does your child have any known handicaps (mentally, emotionally or physically) that would limit his/her participation in our Education Program
Please write your answer here, you may put N/A if this question is answered no
Has your Child Been Diagnosed with any of these learning disablilities?
If your Child has been diagnosed with any of the previous listed disorders please describe treatment plan.
The Plan may include medicines, counselling etc... please enter N/A if this does not apply to your child
Are there any conditions your child had that require special consideration
Please List any Food or Environmental Allergies your child may have
Please enter any Medication Allergies your child may have
Do you give RCA permission to administer medicine to your child?
Please check the Box before each allowed medication
Tylenol for headaches or minor body aches
NSAIDs for Pain (not including Aspirin)
Aspirin for headaches or body aches
Papaya for upset stomach
Tums for upset stomach
Pepto Bismal for upset stomach (contains Aspirin)
Benadryl (Dipenhydramine) for Allergic Reactions
Hydrocortisone Cream for Allergic rashes
Triple antibiotic cream and Band aids for minor injuries
Prescribed Medicines (must be in the prescription bottle correctly labeled
Name of Parent Filling this form
Please enter the name of the parent filling this form with medical information
By entering my pin number I understand every effort will be made to contact parents or guardians of the child named above. In the event I cannot be reached in such a situation , I hereby give permission to RCA to hospitalize and secure proper treatment for my child
Please enter your pin number if you agree to this statement
By entering my pin I release and discharge Ridge Christian Academy, its Agents, employees and officers from all claims, demands, actions and judgments, which my heirs, executors, administrators, or addings may have or claim against RCA, its successors or assigns, for all personal injuries, known or unknown, which my child had or may incur by participating in activities sponsored by RCA. I have read this release and understand all of its items. I execute it voluntarily and with full knowledge of its Significance.
Please enter your pin in agreement to this statement
Send me a copy of my responses.
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