Tools & Resources

Sample Curricular Medical Information and Acknowledgement of Elements of Risk Form

Description

PLEASE NOTE: FREEDOM OF INFORMATION- The information provided on this form is collected pursuant to the Board’s education responsibilities as set out in the Education Act and its regulations. This information is protected under the Freedom of Information and Protection of Privacy Act and will be utilized only for the purposes related to the Board’s Policy on Risk Management. Any questions with respect to this information should be directed to your school principal.

Parents/guardians are requested to complete this medical information form and acknowledgement of Elements of Risk Notice and return to their child/ward’s teacher.

(Where your child’s/ward’s condition is confidential or requires further explanation you are requested to contact your child’s/ward’s teacher.)
Is your child allergic to any drugs, food or medication/other?

Medic Alert Information

Does your child/ward wear a medical alert bracelet?
Does your child/ward wear a neck chain?
Does your child/ward carry a medical alert card?

Oral and Visual Appliance

Does your child/ward wear eyeglasses?
Does your child/ward wear contact lenses?
Does your child/ward wear orthodontic appliance?
Does your child/ward have dental restorations (that is, crowns, bridges)?

Medical Conditions

Indicate if your child/ward has been diagnosed as having any of the following medical conditions and provide relevant details:

Medications

Does your child/ward take any prescription drugs?

Physical Ailments

Indicate any physical ailments that apply and provide relevant details:

Concussion

Has your child/ward previously been diagnosed with a concussion?
[month/day/year]
If your child/ward is presently diagnosed with a concussion by a medical doctor/nurse practitioner, that was sustained outside of school physical activity, a Medical Concussion Assessment Form must be completed before the student returns to physical education classes and daily physical activity (DPA). Request the form from the school administrator.

Other Conditions

Elements of Risk Notice

I acknowledge and have read the Elements of Risk notice in the Curricular Parent/Guardian Letter.

Attached Resource

Jun. 03, 2019

Sample Curricular Parent/Guardian Letter

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