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Students Medical Card / Tarjeta de Salud de Alumnos
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* Indicates required question
Email
*
Your email
Surname / Apellidos del Alumno
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Your answer
Name(s)/ Nombre(s)
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Your answer
Grade / Grado
1st
2nd
3rd
4th
5th
Clear selection
Father's Name / Nombre del Padre
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Your answer
Mother's Name / Nombre de la Madre
*
Your answer
Home Telephone / Teléfono de Casa
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Your answer
Office Phone / Teléfono de Oficina
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Your answer
Parent's Cellphone / Celular del Padre o Madre
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Your answer
My child may take one dose of the following medication if needed / Autoriza dar una dosis de estos medicamentos en caso de ser necesario
*
Melox plus ( Hidróxido de Alumnio, Hidróxido de Magnesio, Dimeticona)
Suspensión Pepto-Bismol (Subsalicilato de Bismuto)
Buscapina (Butilhioscina)
Tylenol, Tempra (Paracetamol)
Advil (Ibuprofeno)
Cloro-Trimetrón (Clorfenamina)
No autorizo/ I do not authorize it
Required
Specific information related to student's health (e.g. allergy, asthma, epilepsy, etc.). / Información especial pertinente a la salud del alumno (Ej. alergias, asma, epilepsia, etc.)
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Your answer
Has the student been vaccinated? /¿Su hijo ha sido vacunado contra COVID19?
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Yes
No
Vaccine type and number of doses. / Tipo de vacuna y número de dosis.
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Your answer
I certify that I have read and completed the Student Health Medical Card Form, therefore I accept the use of this information for the care of my child.
/ Hago constar que conozco, que he leído y completado el Formulario de Tarjeta Medica de Salud del Alumno por lo que acepto el uso de esta información para la atención de mi hijo(a).
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Your answer
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