Medical Health Form | Changemaker School

Health/Allergy/Medical Form

Please fill out the following form to help us understand your child's allergy, medical and/or health needs.

Student First Name

Email Address

Student Last Name

Date of Birth

List all allergies and/or medical conditions:

Describe severity, signs of a reaction and/or what constitutes a medical emergency related to condition(s):

List all medications the student is currently taking and/or would take in the event of an emergency and how/when to administer (dosage, frequency, storage, side-effects):

Describe steps we should take in the event of a reaction or medical emergency from mild to severe (include who to contact and when):

Primary Emergency Contact/Parent

Emergency Phone Primary

Secondary Emergency Contact/Parent

Emergency Phone Secondary

Alternate Emergency Contact and Relationship to Student

Emergency Phone Alternate

Alberta Health Number

Parent/Guardian: By signing below you acknowledge that:

All of the questions above have, to the best of your knowledge, been completed and answered fully and truthfully.

Your child will follow all reasonable safety and health instructions from Changemaker Staff Members and/or Parent Volunteers.

While the Calgary Changemaker School staff will make every effort to follow the instructions in this form within the limits of our best judgement and non-medical expertise, you hereby release the Calgary Changemaker School, its board, staff and volunteers of and from all manner of actions, claim and demands of whatever nature which result from any loss, injury, illness or expense sustained.

In the event your child is injured, ill or in need of immediate medical attention you authorize Calgary Changemaker School staff to seek medical attention on your behalf.

I will promptly inform the school office of any changes or updates to this information.

I agree to the terms & conditions above.

Print Name

Relationship to Student

Your Signature

Today's Date

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