Student Registration Form

Are there any significant medical conditions, physical limitations, or any other concerns that might affect your child’s/ward’s full participation in the course? *

Yes
No

Does your child/ward take prescribed medication on a regular basis? *

Yes
No

Does your child/ward need to have any prescribed medication(s) with him/her during the program? *

Yes
No

Does your child/ward wear or carry medical alert idenfication (e.g. bracelet)? *

Yes
No

If you replied "Yes" to any of the questions above, please provide more information regarding the student's medical needs. If you replied "No", please indicate this by stating "Not applicable". *

Please indicate the degree of severity for the allergies listed. (Please leave blank if the student does not have an allergy.)

Mild
Moderate
Serious
Life-Thretening

Does your child/ward need an EpiPen? *

Yes
No

Does your child/ward need an asthma inhaler? *

Yes
No

If you replied "Yes" to any of the questions above, please provide more information regarding the child/ward's medical needs. If you replied "No", please indicate this by stating "Not applicable". *

Please list all known confirmed food allergies, medication allergies and environmental allergies. If your child/ward does not have any allergies, please indicate this by stating "Not applicable". *

Please list all known dietary restrictions if applicable. If your child/ward does not have any dietary restrictions, please indicate this by stating "Not applicable". *

Should it become necessary for my child/ward to have medical care, I hereby give the teacher permission to use their professional judgement in obtaining the best of such service for my child/ward. I also understand that in the event of such illness or accident, I will be notified as soon as possible. *

I understand and accept these terms.

User Password *

roots to routes academy

roots to routes academy

STUDENT REGISTRATION FORM

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