9800 SE 92nd Avenue • Happy Valley • OR • 97086  •  (503) 788-7000
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Health History Downloadable Form
File Size: 383 kb
File Type: pdf
Download File

    Picture

     Health History Form

    Good from Sept 1, 2019 to Aug 31, 2020
    00/00/0000

    Student Information


    Parent/Guardian 1

    Parent/Guardian 2


    in case of emergency


    Student health

    This health history is correct as far as I understand, and the person herein described, is free of potential health problems which might restrict his or her participation (except as noted). In the event I cannot be reached in an emergency, I hereby give permission to the physician, hospital, clinic selected by the youth leaders to treat, hospitalize, secure proper anesthesia, injections or surgery.
Submit Health History

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