MEDICAL INFORMATION

 

This form should be filled out, signed, and returned to the swim school.  It may be faxed to (770) 772- 0390 for Alpharetta, (770) 451- 6571 for Chamblee.

 

STUDENT’S NAME: __________________________________ AGE:________

 

PARENT’S NAME: ________________________________________________

 

PHYSICIAN: _____________________________________________________

 

PHONE: ____________________________

 

DOES YOUR CHILD HAVE ASTHMA? _________ Yes   _________ No

 

IF YES, ARE THE ATTACKS EXERCISE INDUCED? _____ Yes_____ No

 

IF YES, PLEASE HAVE THE APPROPRIATE MEDICATION IN CASE OF AN EMERGENCY.

 

DOES YOUR CHILD HAVE OTHER SPECIAL MEDICAL CONDITIONS?  IS THERE OTHER RELEVANT INFORMATION ABOUT YOUR CHILD THAT WE SHOULD KNOW IN ORDER TO GIVE THE BEST POSSIBLE SWIM LESSON?  (Please include Attention Deficit Disorder, speech delays, skill delays, allergies, seizures, etc.)

 

 

PARENT’S SIGNATURE: ___________________________________________

 

DATE: _______________