* indicates a required answer.
Please fill out the following Required Medical Information once for your child for the current school year:
Current Term or Season:
Is your child currently taking any medications?
If yes, list all medications your child is currently taking:
List known allegeries (if none indicate "none"):
Date of last physical:
Office Address (include city/state/zip):
Emergency Contact Information: (other than a parent)
In the event of any injury or emergency, if I or my emergency contact cannot be notified, I authorize the individual(s) in charge to obtain emergency medical treatment for my child as deemed necessary by competent medical personnel. I understand that I am fully responsible for any and all charges incurred in the event of such treatment.
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