Medical Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Medical Form

Please attach medical records as required.

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? *

Yes

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: *

Yes

Maybe

Not Sure

Vision Difficulty

Speech Difficulty

Deafness

Asthma

Heart Disease

Diabetes

Epilepsy/Seizures

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.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Academy of Sacred Knowledge. Report Abuse

Forms