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Medical Information Form
You will receive a copy of your registration response at the email entered below:
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* Indicates required question
Email
*
Your email
Who can fill this form:
This form must be filled by a legal guardian of the student being registered.
Full name of the person filling this form:
*
Your answer
Student Information
(Student) Full name:
*
Your answer
(Student) Date of birth:
*
MM
/
DD
/
YYYY
Describe any allergies or other medical conditions, if any, that the student may have:
Your answer
Describe any measures, if any, that the school would be required to take to accommodate the student's medical condition(s) for in-person learning:
Your answer
Please describe the severity of a potential medical episode that could occur due to the medical condition(s) of the student:
Your answer
Please state the action(s) to be taken in case of a medical episode:
Your answer
Please list any medication / epipen that the parent / guardian would need to provide to the school:
Your answer
Emergency Contact Information
Please specify the details of individuals (parents, guardians, or others) to be contacted in case of medical emergency (name, relation to student, phone number).
(Emergency Contact 1) Full name:
*
Your answer
(Emergency Contact 1) Relation to student:
*
Your answer
(Emergency Contact 1) Phone number:
*
Your answer
(Emergency Contact 1) Email:
*
Your answer
Secondary Contact
(Emergency Contact 2) Full name:
*
Your answer
(Emergency Contact 2) Relation to student:
*
Your answer
(Emergency Contact 2) Phone number:
*
Your answer
(Emergency Contact 2) Email:
*
Your answer
Student's Doctor Information
(Doctor) Full name:
*
Your answer
(Doctor) Phone number:
*
Your answer
Documents required
Student documentation required:
Health card
Birth certificate
Immunization record
COVID-19 certificate, if available
Please submit all documentation listed above, either using the
Medical Documentation Form
, via email to
sidneyledsonschool@gmail.com
, or as a hard copy
.
Please indicate the number of COVID-19 vaccinations received. This information is needed for Toronto Public Health in case of a school outbreak:
*
Your answer
Please indicate whether or not you consent to the school administering medication on your behalf on receiving instructions from you via phone, email, or hand-written notification. If you provide consent, please note that the school will not be held responsible or liable for any health issues arising from the administering of the medication as directed:
*
I consent
I do not consent
Agreement to Terms of Service
Please read the
Terms of Service
:
Should you require any further clarification, please do not hesitate to email
sidneyledsonschool@gmail.com
.
Check to confirm you have read, understood, and agreed to the terms of service, linked above.
*
I have read, understand, and agree to the linked terms of service
Required
A copy of your responses will be emailed to the address you provided.
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