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:
In case of Emergency contact Parents/or
Medical Insurance Plan No.
Student has received the regular immunization program administered in Alberta schools, ie., tetanus and
diphtheria, typhoid, smallpox and polio vaccine? Yes
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?
Skiing (Cross Country)
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
Chest and Ribs
Student is subject to:
High Blood Pressure
Wears Contact Lenses
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:
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.