Ruth Alpha-Centauri Pathfinder Medical Form 2020-2021
Kindly fill out all information as carefully and as accurately as possible.
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Email *
Child First Name *
Child Last Name *
Date of Birth (YYYY/MM/DD) *
Gender *
OHIP/Health Card
Expiration Date
Child's Home Address *
Child's Home Phone Number *
Family Physician Name *
Family Physician Address
Family Physician Phone Number *
Medical History: Kindly select all that applies. *
Allergies: Kindly select all that applies. *
Does your child take any medication(s) that we should be aware of? *
Is your child currently taking medication? *
Kindly list the medication(s) your child takes. Please also include any specific/special instructions, if applicable.
Date of last tetanus shot (YYYY/MM/DD)
Date of polio immunization booster (YYYY/MM/DD)
List and explain any restriction of activities for medical reasons.
Emergency Contact - Please include full name, relationship to child and contact information. In case of illness or accident, notify the following: (You may list up to 3 contacts, please put in order of priority - thank you) *
In the event I cannot be reached in an emergency, I hereby give permission, to the physician, selected by the adult leader in charge, to hospitalize, secure proper anesthesia, or to order injection, treatment or surgery for my child. A photostatic copy of this shall be as valid as the original. *
By typing my name below, I the Parent/Guardian of the above Pathfinder listed above, certify that this health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. *
Date Signed (YYYY/MM/DD) *
Any further suggestions from parent/guardian:
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