Health Form

Student Health Form

Please fill in the form below as completely as possible. If something does not apply type N/A.
The information on this form will be shared with the appropriate Achieve staff that work directly with your child.

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Student Name *

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During Camp or Sessions at Achieve, does your child require any medication? If yes, please include medication name(s) and dosing instructions. *

During camp or sessions at Achieve, does your child need help with a medical condition? (diabetes, nebulizer, etc.) If yes, please include procedures and other important information about their condition. *

Does your child have any other condition which causes the daily possibility of a life threatening emergency? (asthma, cancer, heart condition, nut allergy, severe allergic reaction, transplant, etc.) If yes, please provide information about the signs or symptoms related to the condition and specific steps you would like staff to take. *

Use this box to make Achieve staff aware of any other medical conditions, concerns or procedures your child has or information we need to be aware of about your child's general health. *

In the event of an emergency, I undersigned, do hereby authorize Achieve staff to contact Emergency Medical Services to render such treatment as may be deemed necessary in an emergency for the health of aforesaid child. In the event parents or others named on the student information form cannot be contacted, Achieve staff are hereby authorized to take whatever action deemed necessary in their judgement for the health of said child. *

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Please keep this form up to date and notify Achieve of any changes in medical conditions that may impact your child while attending camp or sessions at Achieve.

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