9800 SE 92nd Avenue • Happy Valley • OR • 97086 • (503) 788-7000
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Online Preschool Registration
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Indicates required field
Online Health History Submission
Today's Date
*
______/______/__________
Children/Youth Information
Name
*
First
Last
Choose One
*
Male
Female
Date of Birth
*
Student Email
*
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
School
*
Grade
*
Home Phone
*
Student Cell Phone
*
Cell Carrier
*
Can recieve text message reminders about upcoming events, deadlines, and schedule changes
*
Yes
No
Parent/Guardian 1
Name
*
First
Last
Relationship
*
Cell Number
*
Email
*
Home Number
*
Parent/Guardian 2
Name
*
First
Last
Relationship
*
Cell Number
*
Email
*
Home Number
*
in case of emergency
Emergency Contact (Not Parent/Guardian 1 or 2)
*
First
Last
Relationship
*
Phone Number
*
Children's health
Physician Name
*
Health Insurance Info
*
List All Drug Allergies
*
List All Food Allergies
*
List all Environmental Allergies:
*
Physician Office
*
History of:
*
Heart Disease
Epilepsy
Convulsions
Diabetes
Asthma
Rheumatic Fever
Has Been Vaccinated For:
*
Mumps
Measles
German Measles
Has Had:
*
Measles
German Measles
Chicken Pox
Hepatitus
Wears:
*
Glasses
Contacts
Date of Tetanus Booster
*
List all medications
*
Parent / Guardian E-Signature (Full name & DOB)
*
Will student be responsible for own medication?
*
Yes
No
May student be given Tylenol/ibuprofen for headaches and/or minor injuries?
*
Yes
No
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