Medical Form

Student's Name *

Blood Type(if known)

Gender *MaleFemale

Date of BirthM/D/Y

Next of Kin

Phone

Ontario Health Card Number

OR Other Health Plan Number

Name of Insurer

Family Physician's Name *

Phone Number *

May we give your Physician's name and address to a local doctor for purposes of obtaining copies of medical records? *YesNo

Address

Signature of parent *

(or adult student)

Date *

PART A:

PLEASE ATTACH EITHER A COPY OF YOUR RECORD OF IMMUNIZATION OR YOUR ORIGINAL COMPLETED EXEMPTION FORM.

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The Niagara Region of Public Health in compliance with Ontario Law must have either a copy of the record of immunization or the original completed exemption form. Copies of exemptions forms are NOT ACCEPTED. Immunization records are reviewed annually. Students may be suspended from school if requirements are not met.

Please return both sides of the completed form to the
Admissions Office of Great Lakes Christian High School
By one of the following methods:
Email: study@glchs.ca
Fax: 905-563-0818
Mail: 4875 King Street, Beamsville ON Canada L3J 2J1

PART B:

THE FOLLOWING SHOULD BE ANSWERED FOR OR BY THE APPLICANT:

Give details of stays in the hospital (within the last 3 years)

Answer each question with No or Yes. If "yes" State details of treatment you require.
Do you have any of the following conditions?

DiabetesNo

Yes

EpilepsyNo

Yes

AsthmaNo

Yes

Hay FeverNo

Yes

FaintingNo

Yes

ADHD/ADDNo

Yes

Sleeping DisordersNo

Yes

Heart ProblemsNo

Yes

Mental Health ConcernsNo

Yes

State medications you are currently taking. *Give details of dosage level and when and how often medication is taken.

State any allergies you have and the severity. *Give details of medication, precautions, etc.

Detail any other medical conditions or health challenges. *

Detail concerns you might have about participation in Physical Education classes. *

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