Forms

School Entrance – Health Information Form

Please complete the following Health Information Form as part of your education application process. All information is confidential. Please ensure you complete all required fields and include any requested documentation.

Student’s name*
Grade*
Date of birth*
MM slash DD slash YYYY
Gender*
Mailing address*
City*
Province*
Postal code*
Email*
Primary phone*
Parent (Guardian) Information and Emergency Contact
Name of mother or legal guardian*
Primary phone*
Name of father or legal guardian*
Primary phone*
In case of emergency, please provide contact information.
Emergency contact name*
Emergency contact primary phone number*
Student Medical Information
To the best of your knowledge, has there been any problems with the following?
Allergies (food, insects, drugs or latex)*
- Yes
- No
Additional information
Allergies (seasonal)*
- Yes
- No
Additional information
Asthma or breathing problems*
- Yes
- No
Additional information
Attention-Deficit/Hyperactivity Disorder*
- Yes
- No
Additional information
Behavioral problems*
- Yes
- No
Additional information
Developmental problems*
- Yes
- No
Additional information
Bladder/bowel problems*
- Yes
- No
Additional information
Cerebral Palsy*
- Yes
- No
Additional information
Cystic Fibrosis*
- Yes
- No
Additional information
Dental problems*
- Yes
- No
Additional information
Diabetes*
- Yes
- No
Additional information
Head or spinal Injury*
- Yes
- No
Additional information
Hearing problems or deafness*
- Yes
- No
Additional information
Heart problems*
- Yes
- No
Additional information
Hospitalizations*
- Yes
- No
When and why?
Muscular problems*
- Yes
- No
Additional information
Seizures*
- Yes
- No
Additional information
Speech problems*
- Yes
- No
Additional information
Surgery*
- Yes
- No
When and why?
Vision problems*
- Yes
- No
Additional information
Other
I would like to further discuss, in person, the health information provided in this form with the school authority.*
- Yes
- No
Date*
MM slash DD slash YYYY
Full name of applicant or parent*

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School Entrance – Health Information Form

Parent (Guardian) Information and Emergency Contact

Student Medical Information