Medical Information

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Medical Information

Please utilize this form to inform us of any medications, dietary restrictions, and allergies you may have.

Student/Staff Full Name *

Parent Completing this form *

Date of Birth *

YYYY

Address *

Phone number *

Please select any items that may not be consumed

Allergy

Religious Belief

Dietary Restriction

Shellfish -crab, lobster, shrimp

Meat/Poultry

Dairy

Egg

Peanut

Treenut -cashew, almond, macadamia, etc

Lactose Intolerance

Fruits

Other -identify below

Please list any other dietary restrictions

Please select any that apply as a medicinal restriction

Allergy

Ibuprofen

Aspirin

Penicillin

Tylenol

Motrin

Other -identify below

Please list any other medicinal restrictions

Please select all that apply

Diagnosed

Migraines

Diabetes

High Blood Pressure

Low Iron

Asthma

ADHD

Epileptic

Bipolarism

Anxiety

Autism

Other -identify below

Please list any other health related issues -stressors, mental health, etc.

Emergency Contact Name/Relationship *

Please give a contact person to reach out to if you are unavailable.

Emergency Contact Number *

Emergency Contact Name/Relationship *

Please give a contact person to reach out to if you or the contact are unavailable.

Emergency Contact Number *

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