Wab.edu

dear parents: please complete this form in english and submit together with the application materials.
student name family name, first name, middle name
date of Birth day/month/year
grade applying for
student health history
Please indicate if your child has or has had any of the medical conditions listed below.
Medical Condition
Medical Condition
If you have answered yes to any conditions, please provide further details: Have there been any other past medical problems? _______________________________________________________________________________________________________________________________________________________________________ Does your child take any medication on a regular basis? If so, please give full details: _______________________________________________________________________________________________________________________________________ perMission to adMinister MediCation
With your permission, the school nurse can administer the following without contacting you first. Should your child complain of minor pain or other problems while at school, the school nurse WILL administer mild over-the-counter medications such as: • Tylenol/Panadol, Ibuprofen (non-aspirin) • Topical ointment for rashes, etc.
i give permission for the school nurse to administer listed above
if you have answered no, please clarify: ___________________________________________________________________________________
MediCal insuranCe inforMation
parent agreeMent and Consent
• In the event that my child becomes ill and needs to go home, it is my responsibility to arrange transportation • I understand that my child will undergo health screenings by the school nurse.
• I understand that in the event of a medical emergency, every effort will be made to notify parents as soon • I consent to emergency procedures and any treatment deemed necessary in case of injury, accident or illness, and I shall not hold WAB liable in a court of law.
 i have read and agree to the terms above.
____________________________________________
_______________________________
WAB requires new students to have a physical examination within 6 months prior to their enrollment date. Please have your doctor complete the form below and return to us before your child’s start date at WAB.
to the doctor: please complete a physical examination of the student named below.
student name family name, first name, middle name
date of Birth day/month/year
additional
Comments
Medication - is this student taking any medication (oral or injected) on a regular basis?
 no  yes, please explain: ______________________________________________________________________________
______________________________________________________________________________________________________________
required iMMunization
The below immunizations must be current before a student is enrolled at WAB. Please write the DATES for BOTH the scheduled and booster immunizations. Some vaccines are combined or given together; please enter the date of each vaccination in the appropriate box. Please attach a copy of your child’s immunization records and complete the following below: type of Vaccinations
immunization dates (Day/Month/Year)
oral (opV) or
inactivated (ipV)
diphtheria, pertussis, tetanus
(dpt*, dtap*)
tetanus Booster (td/dt)
(every 5-10 years)
Measles/Mumps/rubella (MMr)
(at least 2 doses)
hepatitis B (3 doses)
hepatitis a
Japanese encephalitis (3 doses)
rabies (3 doses)
doctor’s name (Block Letters)
date of examination day/month/year
telephone
email address
signature

Source: http://www.wab.edu/sites/default/files/pdf/admissions/wab-admissions-student-health-form.pdf