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.

Name of Student:Date of Birth:Name of Parent/Guardian:Home Phone:Business Phone:In case of Emergency contact Parents/or:Family Doctor:Medical Insurance Plan No.Medical/Allergy Alert:

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:

Other:

*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:

REMARKS:

PREVIOUS SURGERY: 

Student is subject to:

Allergies (describe):Other:

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:

Name of Medication(s):Purpose of Medication:I/WE are satisfied that our son/daughter

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:

(school name)

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.