_____________________________________                     _______________________________
Last Name                                      First Name                           Telephone Number

______________________________________________________________________

Street Address                                           City                               State              Zip
 

________________________                         ___________________________                      ___________
Date of Birth                                                     Social Security #                                                  Male/Female
 

Have you had any illnesses that a physician treating you should know about?     Yes____   No____
If yes please explain:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Are you currently taking any medication (s) ?            Yes____  No____
If yes, please list the medication (s) and dosage (s):
_______________________________________________________________________________________
_______________________________________________________________________________________

Are you allergic to any medication (s)?          Yes____  No____
If yes, please list the medication (s):___________________________________________________________
_______________________________________________________________________________________

Who is your principal care physician?
Name:                       _______________________________________________________________________
Address:                   _______________________________________________________________________
Telephone Number:  _______________________________________________________________________

Who should we notify in case of an accident or medical emergency?
Name:                       _______________________________________________________________________
Address:                    _______________________________________________________________________
Relationship:              _______________________________________________________________________
Telephone Number:    _______________________________________________________________________

Please list the name (s) of your health/accident insurance carrier (s) and appropriate policy certificate number (s):

____________________________________________                             ______________________________
Name of Carrier                                                                                            Certificate Number

____________________________________________                              ______________________________
Name of Carrier                                                                                             Certificate Number
 

Please list any additional comments so that we can best suit the needs of your child:  _______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
 
 

____________________________________                                                        ___________________________
Signature of Parent/Guardian                                                                                   Date