Medical Form
Synergy Magnet K12
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Email *
Child's Name *
Child's DOB *
MM
/
DD
/
YYYY
Parent/Guardian *
Parent/Guardian Phone Number *
Parent/Guardian 2 Name
Parent/Guardian 2 Phone Number
Emergency Contact Name *
Emergency Contact Phone Number *
Physician Name
Physician Phone Number
Medical Insurance Company *
Policy Number *
Medical History (If necessary, describe the nature and severity of any physical and/or psychological ailment, illness, weakness, limitation, handicap, disability, or condition, to which your child is subject to, and of which the staff should be aware of, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken) *
For your child's safety and our knowledge, your child is a: *
Does your child have the following allergies *
Required
Please Explain Allergies
Does your child take medications regularly or as needed? (Y/N Please Explain) *
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