Search... 
    
Home | Policy Table of Contents

HICA Health Certification And Parents’/Guardians' Waiver - Exhibit 6

 

# 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:

Home Phone:

 

Office Address:

Business Phone:


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:

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


Other:


*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:


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

Knee

Lower Leg

Ankle

Foot

Chest and Ribs

Abdominal (Stomach)


REMARKS:


PREVIOUS SURGERY:

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

Allergies (describe)

 
Other:


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.



(Signature of Parent/Guardian)

(Signature of Parent/Guardian)



Dated:

Dated:



(Signature of Physician)

(Signature of Student)



Dated:

Dated:

Prepared for USIC by: Aon Reed Stenhouse


  

Home | Policy Table of Contents