***NAME OF APPLICANT
Home Phone #
The school will not administer any medicines or screening to children without written permission from their parents. We urge you to complete this form as accurately as possible and return it with the application. Should you need any clarifications, please do not hesitate to contact us:
Yes, the school nurse has my permission to give my child over-the-counter medicines (e.g. analgesia, antipyretic, cough medicines, and throat lozenges) or antiseptic agents for wounds (in case needed).
Yes, if any child or legal ward of mine enrolled at TWA appears to require immediate medical treatment and/or surgery where neither my spouse nor I are available to authorize a doctor to proceed therewith, I authorize the Headmaster, or, in his absence or inability to act, the VP, to take whatever action is deemed necessary to ensure the provision of any necessary permit or authorization.
Yes, I hereby authorize the school nurse to release information contained in this document to other health professionals or school administrators whenever it is medically needed for the care of my child.
Information requested herein in addition to the school screening examination are done in order to ensure that our students are at their maximal learning capacity and able to participate in the various school activities. They are not a replacement for your child’s physician’s medical assessment.
Yes, the school nurse has my permission to perform a physical screening (height and weight measurements, dental, and vision check) for my child
STUDENT MEDICAL HISTORY (TO BE COMPLETED BY PARENT/GUARDIAN)
Check any of the following the student has or may have had (please note: none of the information on this form will be used in admissions decisions):
Does the student have any other medical condition about which TWA should be informed? Yes No
If yes, please explain
1. Is your child taking medication(s)? Yes No
2. Does your child have allergies to medications? Please list.
3.Any other allergies? Yes No If yes, type and discription of symptoms
4. Does your child wear glasses or eye contacts? Yes No
5.Does your child have a prosthesis (medical device)?No If yes, type and discription of symptoms
My signature acknowledges that I have read and understood all the above.
Signature (Parent or Guardian): Date: