Medical Information: The answer to these questions will help us to know if your child has any medical problems. We need this information in case they should become ill and we would be unable to reach you right away. Please circle the appropriate answer. Been in hospital Yes No Bladder or Kidney Yes No overnight infection Tubes in ears Yes No Burning when Yes No Is your child in Yes No urinating special education class in school Any allergies or Yes No Seizures, fits, or Yes No Does your child get Yes No reactions to medicine, shaking spells along with other DTP or other shots or children insects Asthma or wheezing Yes No Heart murmur Yes No Is he/she usually Yes No happy Speech or hearing Yes No Able to play as hard as Yes No problems other children More than two ear Yes No Bumpy, swollen Yes No infections in a year reaction to the TB skin test Tonsillitis Yes No Hemophiliac (free Yes No bleeder) Trouble with his/her Yes No On a heart monitor Yes No eyes or seeing Medical Information Continued:
Medical Information: The answer to these questions will help us to know if your child has any medical problems. We need this information in case they should become ill and we would be unable to reach you right away. Please circle the appropriate answer. Been in hospital overnight Yes No Bladder or Kidney infection Yes No Tubes in ears Yes No Burning when urinating Yes No Is your child in special education class in school Yes No Any allergies or reactions to medicine, DTP or other shots or insects Yes No Seizures, fits, or shaking spells Yes No Does your child get along with other children Yes No Asthma or wheezing Yes No Heart murmur Yes No Is he/she usually happy Yes No Speech or hearing problems Yes No Able to play as hard as other children Yes No More than two ear infections in a year Yes No Bumpy, swollen reaction to the TB skin test Yes No Tonsillitis Yes No Hemophiliac (free bleeder) Yes No Trouble with his/her eyes or seeing Yes No On a heart monitor Yes No Medical Information Continued:
2017-2018_after_school_program_application.docx