Health Form

Student
Please enter the grade level of this student for the current school year.
Student Address
Parent 1
Phone Numbers
Please provide one or more phone numbers that should be called in an emergency.
Parent 2
Phone Numbers
Please provide one or more phone numbers that should be called in an emergency.
Physician
Medical Insurance
Emergency Contact 1 (Must be different from Parent 1 and Parent 2)
Phone Numbers
Please provide one or more phone numbers that should be called in an emergency.
Emergency Contact 1 Address
Medical Conditions & Indications
This information is necessary so that it can be provided to ambulance or other medical personnel in case of an emergency.
Allergies and Medication
Please list only medication that will be brought to classes at My French Classes. State Law requires that all prescription medication is labeled with prescription number, date filled, prescribing physician's name, name of medication, directions, and patient's name. All medication brought to My French Classes must be deposited in the administrative office upon arrival.NO MEDICATION INCLUDING EMERGENCY MEDICATION SUCH AS EPIPENS AND INHALERS CAN BE BROUGHT TO MY FRENCH CLASSES WITHOUT HAVING FIRST PROVIDED THE NECESSARY PAPERWORK (Medication authorization form completed and signed by your doctor).
Weekday School System
Please download the Immunization Form and kindly return it signed by the student's physician if your child does not attend a school in Maryland.
Authorization
In the case that your child becomes ill during the program, you will be contacted as soon as possible. If the parent or guardian is unable to be reached, the child’s emergency contact will be notified. It is the responsibility of the parents or guardians to arrange for the child to be picked up from the center as soon as possible. In the case that your child or anyone in the immediate household of the child develops a reportable communicable disease as defined by the Maryland Board of Health, it is the responsibility of the parent to notify My French Classes as soon as possible in order for My French Classes to take proper action. My signature authorizes the management and staff of My French Classes to act for me according to their best judgment in the event of a medical emergency and/or routine medical care. I/we grant permission for emergency medical treatment and/or routine medical care by My French Classes staff, a rescue squad, or private physician and/or hospital or emergency health care facility staff, under the same circumstances as above, if needed. Any such action will be taken in the best interest of my child and will be reported to me/us as soon as possible. My signature waives and/or releases My French Classes from any and all liability and/or financial responsibility for any medical expenses incurred. Signing below states that all information above is filled completely and correctly to the best of your ability.
Please sign using your legal name.