HEALTH HISTORY AND MEDICAL RELEASE FORM

FOR PARISH PROGRAMS AND ACTIVITIES

HEALTH HISTORY

IMMUNIZATIONS  (Record YEAR of last immunization or last time person had the disease.)

SPECIAL INFORMATION:  (Please check all that apply.  Information will be shared on a "need to know" basis or shared with appropriate staff.

ALLERGIC REACTIONS  (Please list all known allergies - plant, insect, food, medicine AND TYPE OF REACTION):

Please indicate any other medical problems/situations pertinent to your child.

Any emotional/psychological limitations or reactions to be aware of ?

Is the student presently taking any medications?  All medication is to be well labeled with clear, concise directions indicated here (frequently, dosage, etc.)

In an EMERGENCY, and if unable to reach parent/guardian, we should contact: