Medical Form
To be completed by parent or guardian: ( Parents may wish to refer to school records for information)
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  • If you reside in a country, territory or province not listed in the filed above, please include here. (i.e. St. Croix, US Virgin Islands)
  • If you reside in a country, territory or province not listed in the filed above, please include here. (i.e. St. Croix, US Virgin Islands)
  • Check and give approximate dates in the space below:
  • Include Dates
  • Include Dates
  • No
    Yes
  • Section Break

    A description of the section goes here.
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  • If so, please indicate Carrier and Policy Number
  • Immunization History

    Immunizations are required for program participation)
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    (must be in the past six months)
  • This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities, as noted by my signature below. ergency authorization: I hereby give permission to the medical personnel selected by VMI to order x-rays, routine tests and treatment for my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by VMI to hospitalize, give proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above.


    By entering your name and date, you agree to accept the terms of the above document with an electronic signature.
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