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CENTRO DE ACTIVIDADES Y SERVICIOS EDUCATIVOS A. C.

caseac@prodigy.net.mx

 

 

 

MEDICAL FORM

NAME:____________________________________________________AGE:_______________________
BIRTHDATE:__________________________________________________________________________
ADDRESS:____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EMAIL:_______________________________________________________________________________

PARENT'S NAME:______________________________________________________________________
TELEPHONE HOME:___________________________WORK :___________________________________

PARENT'S NAME:______________________________________________________________________
TELEPHONE HOME:___________________________WORK :___________________________________

IN CASE OF AN EMERGENCY A THIRD PERSON TO CALL:______________________________________
____________________________________TELEPHONE: _______________________________________

NAME OF STUDENT'S DOCTOR:__________________________________________________________
TELEPHONE:_____________________24 HOURS:____________________________________________
IS YOUR SON OR DAUGHTER ALERGIC TO ANY MEDICINE?   YES______   NO______
SPECIFY_______________________________________________________________________________
____________________________________________________________________  BLOOD TYPE________
DATE OF LAST TETANUS SHOT OR BOOSTER: ____________________________________________
SPECIFY ANY OTHER ALLEGIES (FOOD, PLANTS, ANIMALS, ETC.) _____________________________
______________________________________________________________________________________

IS YOUR DAUGHTER OR SON TAKING ANY MEDICINES OR UNDER ANY MEDICAL CARE? ________ 
IF THE ANSWER IS YES, PLEASE GIVE ANY AND ALL MEDICINES THAT ARE CLEARLY MARKED
WITH YOUR CHILD'S NAME,  AND WRITTEN INSTRUCTIONS TO THE ACOMPANING TEACHER BEFORE DEPARTURE FOR THE CAMP. ALL MEDICINES MUST BE IN THEIR ORIGINAL PACKAGE.  

COMMENTS OR OTHER INFORMATION WE MAY NEED TO KNOW: _____________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

 


SIGNED: ________________________________ DATE:_________________________________