Does your child have any significant allergies? (Food, insects, medications, etc)? *
If yes, what are they and what are the reactions? Indicate if medication is needed.
Your answer
Does your child have any known vision or hearing problems? *
Your answer
Please indicate if your child has glasses, contacts, hearing devices, or other assistive devices related to vision and hearing.
Your answer
Is your student currently taking any medications or inhalers? *
If yes, please explain which medication and if they will need to be taken during the summer program hours:
Your answer
Within the past year has you child had a significant injury (Concussion, fracture, dislocation), developed a new illness, or had surgery or hospitalization? If yes, please indicate and explain: *
Your answer
Does your child have any health concerns you wish to consult with the nurse about?
Your answer
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