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HOME
ABOUT
ABOUT
PHILOSOPHY
ADMISSIONS
SCHEDULE & TUITION
WAIT POOL
CALENDAR
FORMS
CONTACT
PROJECT YURT
Health Form
Child's Name
*
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
List any special circumstances that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations, and behavioral assessments during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of.
*
IMMUNIZATION
I have provided Bloom with a copy of my child’s most current immunization record.
*
Yes
No
I am working on it
I provided Bloom with a notarized waiver of immunization form.
Yes
No
I'm working on it
I have provided the school with my child's health-care professional's statement.
*
This is a form that your child's pediatrician can provide. You can ask for it at your child's yearly check-up - or they may be able to send it to you via snail mail or email.
Yes
No
I'm working on it
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION
Name of Physician
Physician Phone Number
*
(###)
###
####
Physician's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Emergency Medical Care Facility
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Yes
My typed, full name represents my electronic signature.
*
Thank you!
