Please explain any check marks or �yes� answers to the above questions. Attach an extra sheet if

necessary. Be as detailed as possible. Include dates, dosage of medications, etc:

Section II: Allergies (Check those that apply & specify nature of allergic reaction in space below)

______Animals_______Hay Fever _______Pollen ______Food ______Plants ______Insect stings

______Medicine/drugs Is child currently taking any allergy medication?______________________

______Other
(Specify)________________________________________________________________________

****Explain any checks. Also, please specify type of reaction and symptoms noted, and any particular treatment in case of exposure to allergy or allergic reaction:
*********Turn this page over for other important information


List any adults other than parents who are allowed to pick up and remove your child from the agreed upon premises.  Photo ID will be required.

1. _____________________________________________________________(Name & Relationship)               
    ______________________________________________________________________
    Address:                                                                                                  Phone #

2. ______________________________________________________________(Name & Relationship)               
    ______________________________________________________________________
    Address:                                                                                                  Phone #
This health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my child should not participate in prescribed activities except as noted. If this information changes, I will notify the adult in charge in writing. I understand that this information will remain confidential to the designated person in charge, trained in first aid, or emergency personnel as needed. I hereby give permission to the adult in charge to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the adult in charge to arrange necessary related transportation for my child.

________________________________________________________________________________
(Signature of parent or legal guardian)                                                                                                     (Date this form was signed)


HEALTH FORM AND EMERGENCY INFORMATION
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