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Parental Authorization Forms
Student Medical History
Student Name:
*
(First Name Last Name)
Birthdate:
*
/
/
Please check any of the following illnesses or disabilities your child has experienced.
Please include a copy of your child’s immunization record if not in his/her permanent school record.
PAST DISEASES:
Mumps
Measles
Whooping Cough
Asthma
Hay Fever
Diphtheria
Scarlet Fever
Rheumatic Fever
Chicken Pox
Pneumonia
Polio
Convulsions
Heart Disease
Diabetes
Ear Discharge
RECENT DISABILITIES:
Fainting Spells
Abdominal Pains
Poor Vision
Allergy
Dizziness
Frequent Styes
Dental Defects
4 + Colds Yearly
Frequent Sore Throat
Frequent Urination
Frequent Leg Pains
Persistent Cough
Speech Difficulty
Crippling Condition
Hearing Difficulty
Tires Easily
Shortness of Breath
Hernia (Rupture)
Ringworm
Nose Bleeding
Growing Pains
MISCELLANEOUS QUESTIONS
Does your child have a disability due to disease, accident, or congenital disorder?:
*
Yes
No
If yes, please explain below:
Does your child take any medication for asthma?:
*
Yes
No
If so, please describe:
Has your child had a skin test for TB?:
*
Yes
No
Has he/she been associated with a tubercular patient?:
*
Yes
No
If yes, when?:
Signature of Parent:
*
(First Name Last Name)
About Us
Temple Academy has been serving the Central Maine community with academic excellence for over 40 years!
Call to apply today!
207-873-5325
Address
60 West River Road
Waterville, ME 04901
Phone : 207 873-5325 | 207 660-4224
Email: school.office@templeacademy.org
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