Health Screening

Please fill out the following form.

Parent first name

Parent last name

Parent Email

Parent Phone

Child's Full Name

Child's Date of Birth

Month

Day

Year

Has your child been hospitalized or undergone any surgeries in the last 12 months?

No

Yes

If yes, please explain:

Has a doctor ever said your child has a heart condition and recommended only medically supervised physical activity?

No

Yes

Is your child currently taking any medications that could affect their ability to safely exercise?

No

Yes

If yes, please list medication(s):

Has your child ever been diagnosed with a chronic medical condition (e.g., ashtma, diabetes, epilepsy)?

No

Yes

If yes, please explain:

I declare that the info I’ve provided is accurate and complete.

Parent Signature

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WISEWAY ACADEMY