Youth Health Form

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Please submit this health form on or by the first day of your child’s class, unless you wish a conference regarding their needs. If you have any questions or concerns, contact the Museum School at 413-314-6477 or museumschool@springfieldmuseums.org.

Student Name(Required)

First Last

Birth Date(Required)

MM slash DD slash YYYY

Parent/Guardian Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Daytime Phone(Required)

Emergency of Cell(Required)

Email(Required)

In case of an emergency, please indicate your preference:(Required)

Contact parent or guardian

Call ambulance and transport to nearest hospital

Are there any medical conditions relevant to your child that we should know about?

Diabetes

Heart Condition

Seizures

Asthma that requires medication

Speech impairment

Hearing impairment

Sight impairment

ADHD

Please indicate any allergies you child has

Food, insect bites/stings, medications, skin-contact reactions, etc.

Medications(Required)

My child does NOT take any medications.

My child DOES* take medications.

* Note: This information is necessary in the event of emergency room treatment by an attending physician. Museum Staff are not trained or permitted to administer medications. If medications are to be given to your child during the class, the parent is responsible for giving them.

If your child does take medications, please explain below.

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