Medical Form
for Youth Programs

*PLEASE NOTE - If medical information is the same as what you filled out last year, simply fill out the student's name and click submit form.

Form effective dates: January 1st, 2024 to December 31st, 2024

Fields marked with are required.

Student Information:

Parent/Guardian Information:

Emergency Information:

Medical Information:

Medical History:

In the box below, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.