• STUDENT MEDICAL FORM

    fOUNTAINVIEW ACADEMY
  • MEDICAL QUESTIONNAIRE

  • The Canadian Government has approved the Vaccination Status Reporting Regulation requiring parents or guardians to report the vaccination status of their school-age children. 

    Every student from K to 12 in public and independent schools and those who are home-schooled will be expected to have their complete immunization records in the Provincial Immunization Registry (the Registry).   

    Although immunizations are not required by Fountainview Academy, we do have to have a record of what each student has received.  

  • Please choose one of the options below (A. Upload a copy of the vaccination record or B. Sign the box below if you do not have a vaccination record and/or do not wish for your child to be vaccinated.)  One of the options MUST be entered.

     

  • Upload a File
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  • B. If you do not have a vaccination record or do not wish for your child to be vaccinated please sign in the box below.

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  • Also, If your child is at risk for anaphylactic reactions to foods and/or other substances (i.e. peanuts, walnuts, wasp stings, etc.) Fountainview Academy requires a written note from your doctor stating a diagnosis of anaphylaxis. Your child should also come with 2 EpiPens, and a written prescription for additional EpiPens.  

  • Please check the corresponding box for each condition that your child currently has or has had in the past. Please type in any relevant comments pretaining to the condition in the box below.

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  • EMERGENCY CONTACT INFO

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  • Non-Parent Emergency Contact Info

    Please list at least one (1) emergency contact (and at least one phone number for them) that is NOT a parent/guardian. This would be someone that we would contact in case of emergency regarding your child if parents/guardians cannot be reached. 

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