MEDICAL INFORMATION • 2017/2018 SCHOOL YEAR Medical Conditions Which Could Affect Your Child’s Medical Treatment (e.g. Nut or Medication Allergies, Diabetes.):Any Medications to note?NOYESMedications and AllergiesPlease list all medications and allergies the child has. Has this child been medically diagnosed as Anaphylactic?NOYESIs he/she required to carry an Epi-Pen?NOYESConfirmation of Anaphylactic Diagnosis by: First Last Doctor's Name pleaseDoctor's SignatureYou can also upload a signed document by the Doctor.Dietary Restrictions/Preferences (e.g. No Wheat, Vegan, etc.):NOYESPlease List Dietary Restrictions or Preferences Any additional Medical information you would like to provide?Immunization RecordsImmunization ListPlease complete this section even if no immunizations have been given. We ask for this information primarily for our records so that if there is an outbreak of a communicable disease in our community, we know who to contact to be aware of the problem. We withhold any judgement of whether or not you choose to have your child immunized. This information will be shared with Interior Health if requested. DPT (Diptheria, Pertussis, Tetanus) MMR (Measles, Mumps, Rubella) Polio HIB None Other Please List other Immunizations Has this child had Chicken Pox?(for B.C. Ministry of Health statistical purposes)YesNoHomeopathyPart of our school’s First Aid Kit is stocked with Homeopathic Remedies. We are requesting your permission to administer these to your children, should the need arise. These remedies are natural, do not cause any side-effects and are extremely beneficial in first-aid situations such as twists, sprains, cuts, bruises and stings. The remedies we use are of low potency and designed from the occasional scrapes and falls that take place on our playgrounds. If you support your child receiving these remedies, please sign below. If you would like more information, in general, or about specific remedies and their application, we would be happy to provide you with details.I/we support the use of Homeopathic remedies for my child in the Nelson Waldorf School.I/we do not support the use of Homeopathic remedies for my child in the Nelson Waldorf School.Medical ReleaseIn case of accident or illness of the above child while at school and the parent/s or emergency contact person/s cannot be reached, I agree to allow the staff of the Nelson Waldorf School to obtain the necessary medical attention which may include ambulance services, contacting the family doctor or if not available, another qualified physician.I have read and understand the above stated,Signature Parent/Legal GuardianDate PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.