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General Information

Student´s Name:

Tutor/Guardian´s Name:

Home Telephone :

Office Telephone:

Emergency Telephone:

Name of the Student´s personal physician:

Telephone:

Student´s date of birth:

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Medical History

PREVIOUS CONDITIONS (Such as diabetes, seizures, etc.).

ALLERGIES (Caused by insect bites, aspirine or by any other).

PAST MEDICAL CONDITIONS (Suchs Hernia, Fracture of bone, Surgery, etc.)

IMMUNIZATIONS::

POLIO
D.P.T.
M.M.R.
B.C.G.
HEPATITIS B
TETANUS
BOOSTER
MENINGITIS

BLOOD TYPE:

Factor:

ADDITIONAL INFORMATION:

IMPORTANT: Parent/Guardian is responsible of advising the Health Office through a note or telephone call of any change in the information supplied in this form.

I authorize Saint George School to the take my child to the Health Center deened convenient in case of on emergency if it is not possible to contact me.