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: *
Yes
No
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.  
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