Doing What’s Best for Kids

Instructional Programs and Materials AP 260 - Form 260-3: Health Certification And Parents’/Guardians’ Waiver

To print or fill out Form 260-3 online please click here.


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.

Parent/Guardian Signature: 

Please check the category or extra curricular activities and individual sports below he/she can take part in:

Aquatics Curling Scuba Diving
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
Basketball Golf Wrestling*
Broomball Hiking Volleyball
Camping Rugby  
Cross Country Running    
All Activities Listed    

*Those with an asterisk must have a doctor’s certificate

Please note any health concerns, physical capacity limitations, emotional/social/behavioural considerations, or other information which may limit full participation in the program:

PREVIOUS INJURIES: (sprains, strains, fractures, torn muscles, ligament injuries, dislocations)
If yes, check below and describe:

Skull  Fracture  Upper Arm
   “Knock Outs” or concussions  Elbow
Face Injury:  Eye  Forearm
   Ear  Wrist
   Nose  Hand
Spine:  Neck  Pelvis
   Lower Back  Hip
   Shoulder  Upper Leg
     Lower Leg
     Chest and Ribs
     Abdominal (Stomach)



Student is subject to:

Asthma Ear Ache Fainting
Tonsillitis Eye Infection(s) Sensitive Skin
Sinus Trouble Frequent Colds Nightmares
Bronchitis Sleepwalking Convulsions
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)
Dated:   Dated:
(Signature of Physician)   (Signature of Student)
Dated:   Dated: