Health Form (must be signed by Physician)
Please fill out this form and click submit.
Name of Child
*
Date of Birth
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Home Phone
*
Cell Phone
*
Email
*
This address will receive a confirmation email
Height
*
Weight
*
Child's Physician
*
Physician Phone
*
Child's Dentist
*
Dentist Phone
*
What contagious diseases has your child had or have they been vaccinated for?
*
Please select all that apply.
Measles
Mumps
Chicken Pox
Scarlet Fever
Whooping Cough
Is your child subject to nosebleeds?
*
Please select one option.
Yes
No
Does your child wear glasses?
*
Please select one option.
Yes
No
Does your child have a hearing loss?
*
Please select one option.
Yes
No
Does your child have any allergies? Please List
*
Does your child have a physical challenge or condition that we should be aware of? Please explain.
*
Please print Physician Signature form and have it signed by the child's doctor.
Immunizations: Please attach a copy of your child's immunization record.
Submit
Description
Please fill out this form and click submit.
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