EXCEL Summer Health History Form

Note: To be completed only if you marked "yes" on your registration form for
Special Needs or Medical Problems.
Student Information:

Name:
Home Phone: SS#:
Mailing Address:
Birth Date (M/D/Y): Sex: M F
Class Title:
Session: 1 2 3
Class Title:

In Case of an Emergency Please Notify:
Name:
Address:
Home Phone: Work Phone:
Relationship:

Medical Care Information:

Major illness, injury, or surgery Explain:
Are you currently taking any drugs or medications No Yes
If "yes" please list:
Are there any medical problems, including allergies, that we should know about?
(Inhalers, special medicine or bee sting kits which must be carried by students at all times)
Are there any special needs or conditions we should know about? No Yes
If "yes" please list:
Are you allergic to PeniciOLLIn or any medications? No Yes
If "yes" please list:

Parent or Guardian's Signature:
Date:

Please fill out, print, and bring to classroom teachers.