Health Registration Form Student Name * First Name Last Name DOB * Grade * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Legal Guardian * Legal Guardian Phone * (###) ### #### Emergency Contact Person * Emergency Contact Phone * (###) ### #### Student's Physician * Physician's Phone * (###) ### #### Indicate if your child has had any of the following: * Anaphylactic Reaction to foods or insects Anemia Concussion Diabetes Epilepsy Heart Disease Heart Murmur Kidney Problem Pneumonia Rheumatic Fever Whooping Cough None of the above Is your child presently taking any medications? * No Yes If yes, what medicine and for what reason? Does your child have difficulty with vision or wear corrective lenses? * No Yes If yes, please describe: Does your child have difficulty with their hearing? * No Yes If yes, please describe: During the past year, has your child had any serious illness, injury or operation? * No Yes If yes, please describe: Does your child have any dental circumstances that would impact their ability to participate in sports? * No Yes If yes, please describe: Does your child have any allergies that require attention at school? * No Yes If yes, please describe: Should your child be restricted from participation in school sports for any reason? * No Yes If yes, please explain: Affidavit * My child is physically fit and I know of no medical or health reasons why he/she/they should not take part in all athletic activities offered by the Waldorf School of Saratoga Springs. * Thank you!
