CHILD HEALTH FORMThis form is required Please share information about any health conditions or medical needs your child may have. Child's Name * First Name Last Name Does your child have any allergies or food restrictions? * YES NO Allergy Type Medication type Prescribed dosage Please provide additional details, if necessary Does your child need any medication(s)? * YES NO Medication type Dosage Frequency Provide additional details, if necessary I give my permission for Hearts and Minds Learning Community to apply a sunscreen product when my child engages in any outdoor activities: * HMLC may use the sunscreen product of their choice, in keeping with federal and state standards. or HMLC may only use the sunscreen that I have provided. For medical and/or other reasons, please do not apply sunscreen on my child. I give my permission for Hearts and Minds Learning Community to apply an insect repellant when my child engages in any outdoor activities: * HMLC may use an insect repellant of their choice, in keeping with federal and state standards. HMLC may only use the insect repellant that I have provided. For medical or other reasons, please DO NOT apply any insect repellant on my child. In consideration of my child’s admittance, I hereby authorize Hearts and Minds Learning Community to arrange for medical examination and/or treatment of my child should an emergency arise on the school premises or on a field trip. I understand that a conscientious effort will be made by a teacher or staff member to contact me at the numbers I have provided before any medical action is taken, to the extent that such prior notification is medically feasible. I would prefer the hospital of my choice, but fully understand that my choice of hospital may be limited by the service of a local rescue squad. Should my child suffer an injury or illness while in the care of Hearts and Minds Learning Community and the facility is unable to contact me/us immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I/We agree to keep the facility informed of changes in telephone numbers, etc. where I/we can be reached. The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child. The facility will attempt to contact me before calling on emergency services. However, it is understood that in certain critical medical situations, the staff will need to contact local emergency resources BEFORE the parent, child's physician or other emergency contacts. Permission is granted to take my child to the nearest appropriate medical facility, and the facility and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. I agree to accept the financial responsibility for all medical and transportation expenses incurred. It is my understanding that the staff of Hearts and Minds Learning Community will attempt to reach a parent/guardian in case of illness or emergency and if possible to honor the following preferences as to doctor and hospital prior to taking the above action. In consideration of the registration of my child, I release Hearts and Minds Learning Community and their related companies, vendors, directors, officers, employees and agents, and their related companies, vendors, directors, officers, employees and agents, from any claims, losses, damages or costs (including attorneys’ fees) caused by or arising from my child’s registration, use of the school, or participation in the programs and activities conducted by the School other than to the extent caused by the negligent or willful misconduct of the School and their related companies, vendors, directors, officers, employees and agents. Parent/Legal Guardian Name * *this constitutes an electronic signature First Name Last Name Date * MM DD YYYY Thank you for filling out the HMLC child health form.
