(SAMPLE)

MEDICAL FORM

Student's Name __________________________________  Date of Birth ______________________

Address ________________________________________  Telephone  ________________________

Parent/Legal Guardian _______________________________________________________________ 

Parent's Employer  _______________________________  Telephone  ________________________

EMERGENCY PHONE NUMBERS

Day Phone

Father_____________________ Mother_____________________ Friend____________________

Evening Phone (other than home)__________________________________

MEDICAL INFORMATION

Medicines in student's possession_____________________________________________________

List any allergies to medications_______________________________________________________

Date of last tetanus shot_____________________________________________________________

List any pertinent medical history or chronic medical problems______________________________

Date____________________________________