After-School Program Health Information Form

Student Information

Student Name

Date of Birth

Grade

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Emergency Contact

Name

Phone Number

Relationship to Student

Medical Information

Primary Physician

Physician Phone

Health Insurance Provider

Policy Number

Allergies (food, medication, environmental)

Chronic Medical Conditions

List of Medications

Special Needs or Accommodations

Activity Restrictions

Other Important Health Information

Parent/Guardian Consent

I authorize the after-school program staff to obtain medical care for my child in case of emergency.

Parent/Guardian Signature

Date