Medical & Emergency Contact Form

Student Name *

First Name Last Name

MEDICAL QUESTIONNAIRE

Date of last tetanus shot

- Month - Day Year

Please upload a copy of your child's immunization record (immunizations are not required by Fountainview Academy)

Immunization records can also be emailed to info@fountainview.ca or brought to registration day.

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.

Conditions

	Yes
Allergies (seasonal)
Hayfever
Attention-Deficit/Hyperactivity Disorder
Bleeding problems
Carsickness
Dental Problems
Backaches
Diabetes
Head injury, concussions
Headaches
Heart problems
Muscle problems
Seizures
Sinus Issues
Vision Problems
Measles
Chicken Pox
Other

Allergies (food, insects, drugs, latex, etc)

Yes

Has your child been prescribed an EpiPen for allergies? If YES, the EpiPen must accompany your child.

Yes No

Asthma or breathing problems

Yes

Does your child require an inhaler(s) on a daily basis and/or for exercise-induced activities? If YES, the inhaler must accompany your child.

Yes No

Comments regarding condition(s) as checked in any of the "conditions" boxes above

List ALL prescription, over-the-counter, and herbal medications that your child takes regularly. All medications are administered by deans or first aid personnel. Please provide instructions (dose) for administration of medications.

Medical/physical conditions that may affect participation in a program/activity

Name of physician / primary care provider / pediatrician

First Name Last Name

Physician phone pumber

- Country Code - Area Code Phone Number

EMERGENCY CONTACT INFO

Parent/guardian work contact info

	Parent Name	Work Phone (include country code and area code)
1
2

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.

Emergency Contacts (include country code and area code for phone numbers) *

	Name	Relation to Student	Home Phone	Mobile Phone	Work Phone	Email Address
1
2

MEDICAL FORM