Medical & Emergency Contact Form

Student Name *

First Name Last Name

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. This regulation comes into force on July 1 and public health units will begin implementation of the regulation in September of 2019.

When the Regulation is enacted on July 1, 2019, 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 upload a copy of your child's immunization record (immunizations are not required by Fountainview Academy)

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

Date of last tetanus shot

Month Day Year Date Picker Icon

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

Signature of Refusal for Vaccinations

Clear

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.

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 as given by a medical doctor.

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