Health Form 2019/20

Student

Student First Name *

Student Last Name *

US Grade Level *

Please enter the grade level of this student for the current school year.

Student T-Shirt Size *

Student Date of Birth *

Month

Day

Year

Student Address

Student Address *

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Parent 1

Parent Title *

Parent First Name *

Parent Last Name *

Parent Email *

Phone Numbers

Please provide one or more phone numbers that should be called in an emergency.

Cell Phone *

Home Phone

Work Phone

Parent 1 Address (if different from Student address)

If different from Student address above.

Address Parent 1

Country

Address 1

Address 2

City

State

ZIP code

Parent 2

Parent Title *

Parent First Name

Parent Last Name *

Parent Email *

Phone Numbers

Please provide one or more phone numbers that should be called in an emergency.

Cell Phone *

Home Phone

Work Phone

Parent 2 Address (if different from Student address)

If different from above.

Address Parent 2

Country

Address 1

Address 2

City

State

ZIP code

Physician

Physician's Name *

Physician's Phone Number *

Medical Insurance

Insurance Provider

Group Number

Policy Number

Emergency Contact 1

Title *

First Name *

Last Name *

Email *

Phone Numbers

Please provide one or more phone numbers that should be called in an emergency.

Cell Phone *

Home Phone

Work Phone

Emergency Contact 1 Address

Address

Country

Address 1

Address 2

City

State

ZIP code

Relationship to this Student *

Emergency Contact 2

Title

First Name

Last Name

Email

Phone Numbers

Please provide one or more phone numbers that should be called in an emergency.

Cell Phone

Home Phone

Work Phone

Emergency Contact 2 Address

Address

Country

Address 1

Address 2

City

State

ZIP code

Relationship to this Student

Additional Person Authorized to Pick Up this Student (in addition to parents and emergency contacts)

Title

First Name

Last Name

Email

Phone Numbers

Please provide one or more phone numbers that should be called in an emergency.

Cell Phone

Home Phone

Work Phone

Address

Country

Address 1

Address 2

City

State

ZIP code

Relationship to this Student

Medical Conditions & Indications

This information is necessary so that it can be provided to ambulance or other medical personnel in case of an emergency.

Physical

Psychological / Behavioral

Allergies and Medication

All Known Allergies

Symptoms of known allergic or other health condition reactions

Treatment in case of known allergic or health condition reactions

Medication that will be brought to classes

Please list only medication that will be brought to classes at My Language Programs. State Law requires that all prescription medication is labeled with prescription number, date filled, prescribing physician's name, name of medication, directions, and patient's name. All medication brought to My Language Programs must be deposited in the administrative office upon arrival.NO MEDICATION INCLUDING EMERGENCY MEDICATION SUCH AS EPIPENS AND INHALERS CAN BE BROUGHT TO MY LANGUAGE PROGRAMS WITHOUT HAVING FIRST PROVIDED THE NECESSARY PAPERWORK (Medication authorization form completed and signed by your doctor).

Weekday School System

Does your child attend school in Maryland? *

Name of School *

School State *

Please download the Immunization Form and kindly return it signed by the student's physician if your child does not attend a school in Maryland.

Authorization

In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child’s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the center as soon as possible. In the case that your child or anyone in the immediate household of the child develops a reportable communicable disease as defined by the Maryland Board of Health, it is the responsibility of the parent to notify My Language Programs as soon as possible in order for My Language Programs to take proper action. My signature authorizes the management and staff of My Language Programs to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for emergency medical treatment and/or routine medical care by My Language Programs staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me/us as soon as possible. My signature waives and/or releases My Language Programs from any and all liability and/or financial responsibility for any medical expenses incurred. Signing below states that all information above is filled completely and correctly to the best of your ability.

Parent Signature *

Please sign using your legal name.