Medical Information – (Form SM1) Step 1 of 3 33% Medical Information - (Form SM1)Child/ren's Name* First Last Parent's Name* In the event that it is necessary for my son/daughter to receive medical attention while at school or on a school trip, I give the following information regarding my child:Child #1Child #1 NameChild’s date of birth Date Format: MM slash DD slash YYYY Ontario Health Card NoDrugs he/she is allergic to:Specific health problems we should know about:ADD FOR ANOTHER CHILD?YesNoChild #2Child #2 NameChild’s date of birth Date Format: MM slash DD slash YYYY Ontario Health Card NoDrugs he/she is allergic to:Specific health problems we should know about:ADD FOR ANOTHER CHILD?YesNoChild #3Child #3 NameChild’s date of birth Date Format: MM slash DD slash YYYY Ontario Health Card NoDrugs he/she is allergic to:Specific health problems we should know about:ADD FOR ANOTHER CHILD?YesNoChild #4Child #4 NameChild’s date of birth Date Format: MM slash DD slash YYYY Ontario Health Card NoDrugs he/she is allergic to:Specific health problems we should know about: Family doctor’s namePhone noPlease check the box beside the statement. I give my permission for the attending physician to administer any emergency treatment that may be necessary for my child. I also understand that I will be contacted as soon as possible in the event of an emergency. Address Street Address City State / Province / Region ZIP / Postal Code Parent’s signatureDate Date Format: MM slash DD slash YYYY Mother’s Home Phone No.Father’s Home Phone No.If different from aboveMother’s Work No.Mother’s Cell No.Father's Work No.Father's Cell No.Name of another person to contact in case you can’t be reachedNamePhone number
