Medical Form
Please attach medical records as required.
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Student Name: *
Grade: *
If the student has any allergies, please explain:
Does the student carry an EPI-PEN? If so, explain the emergency plan as provided by medical professional.
Does the student require prescription medication to be given at the school? *
I _______________ give consent to Darul Uloom Canada to administer medication.
Fill in he name of the Parent / Guardian giving consent to the school.
Name(s) of Medication
Give names of all medication that need to be given.
Doctor's Name and Office Phone *
Provide the doctor information.
Does the student have any illness or suffer from the following: *
Not Sure
Vision Difficulty
Speech Difficulty
Heart Disease
Learning Disability (ADHD, Autism, Dyslexia)
Behavior Issues (anger, etc.)
Emotional Issues (anxiety)
Mental Health Issues
Please explain the above choices as needed.
Permission Waiver
By submitting this document, I certify that all information is accurate and I give permission to Darul Uloom Canada to contact 911 for medical attention as required, release the above medical information and contact parent in all cases.  
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