NOTE: You may wish to provide supplemental instructions or make alterations to allow easier usage of forms such as this by ESL Parents.
Student has received the regular immunization program administered in Alberta schools, ie., tetanus and diphtheria, typhoid, smallpox and polio vaccine? Yes No
In case of emergency, I hereby give permission to the physician selected by the school to provide necessary treatment for my child.
Please check the category or extra curricular activities and individual sports below he/she can take part in:
|Can Student Swim? Yes No||Cycling||Skiing (Alpine)|
|Badminton||Field Hockey||Skiing (Cross Country)|
|Ball Hockey||Floor Hockey||Soccer|
|Baseball/Hardball/Softball||Football* (Touch or Flag)||Track & Field|
|Cross Country Running|
|All Activities Listed|
*Those with an asterisk must have a doctor’s certificate
Please note any health problems, physical handicap, emotional difficulty, behavioral problem, or facts which may limit full participation in the outdoor program:
PREVIOUS INJURIES: (sprains, strains, fractures, torn muscles, ligament injuries, dislocations)
If yes, check below and describe:
|“Knock Outs” or concussions||Elbow|
|Chest and Ribs|
Student is subject to:
|Tonsillitis||Eye Infection(s)||Sensitive Skin|
|Sinus Trouble||Frequent Colds||Nightmares|
|Headaches||Bed Wetting||Kidney Problems|
|Nosebleeds||High Blood Pressure||Motion Sickness|
|Wears Contact Lenses|
As per AP 260 clause 7.3:
7.3 Reporting and support: Inform the school of any changes in medical information of my student and if I become aware of any concerning behaviour or notice signs of distress in my child or other students, I will promptly report it to the school Principal or in their absence, Vice Principal. The school provides support services and resources to address mental health concerns.
Medications: I would like my child to be given:
is in good health to take part in strenuous activities. He/she has my permission to participate in the extra curricular activities and sports indicated above and conducted by:
I/WE also agree with the need to have our son/daughter examined by a physician following an illness or injury to re-establish the bill of good health; this or any other medical examination is my sole responsibility.
|(Signature of Parent/Guardian)||(Signature of Parent/Guardian)|
|(Signature of Physician)||(Signature of Student)|