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Medical-form

Home / Medical-form

Medical Form

Step 1 of 3 – Medical-form

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Your Personal Information

Your Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone(Required)

Emergency Contact(Required)

First Last

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General Medical History

Is your child up-to-date with all immunizations?(Required)

Yes

Date of last Tetanus or DPT Vaccine:(Required)

MM slash DD slash YYYY

Does your child have any Food, Medication or Environmental Allergies?(Required)

Food

Medication

Environmental

None

Please list and explain any allergies:

Has your child had the Hepatitis B vaccine?(Required)

Yes

Chicken pox (Varicella):(Required)

Yes

Measles:(Required)

Yes

Significant medical history (surgery, injuries, serious illness):

List any medical problems (asthma, seizures, headaches):

Are any medications required?(Required)

Yes

List any medications taken regularly:

In an emergency, does your child require additional assistance to evacuate?(Required)

Yes

Please describe:

In the event that your child care program must be evacuated, are there medications or supplies that must be taken with this child:(Required)

Yes

Medical Insurance Details

Name of Insurance Company:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Number(Required)

Physical Examination

Height:(Required)

Weight(Required)

Our Contact Info

Address:
Yeshivas Lubavitch Toronto
3055 Bathurst St
Toronto, ON M6B 3B7
Canada

Phone: (416) 787-6631
Email: [email protected]