Allergy & Medical Information Form

Student Information

Alberta Health Care Number

Parent / Guardian Information

Primary Contact

Contact Name

Relationship

Phone Number (Home)

Phone Number (Cell)

Email Address

Secondary Contact

Contact Name

Phone Number

Family Physician

Physician's Name

Clinic / Hospital Name

Phone Number

Allergies

Does your child have any known allergies?

Allergy 1

Severity

Reaction Symptoms

Allergy 2

Severity

Reaction Symptoms

Allergy 3

Severity

Reaction Symptoms

Does your child carry an EpiPen?

Does your child carry an inhaler?

Medical Conditions

Additional Details

Medications

Requires medication at school?

Dietary Restrictions

Any dietary restrictions?

Emergency Action Plan

Declaration & Signature

I confirm that the information provided is accurate and agree to notify the school of any changes. I authorize emergency action if required.

Full Name (Signature)

Date

Submit Form