Medical History Update Form

It is very important that the Health Office be kept up to date on any medical conditions or allergies that may affect your student while at school, or school events. Please take the time to complete this form. Please call us at 818-767-8382 x240, or email healthofficestaff@villagechristian.org if you have any additional concerns or questions. Thank you!

Today's date: Today's date: / MM / DD YYYY
Student's Name: Student's Name: First Last
Current Grade:
Birthdate: Birthdate: / MM / DD YYYY
Does your student have any medical conditions? (ie: diabetes, asthma, seizures, etc) If none, state "none".
Does your student have any allergies? (food, environmental, medications, etc) If so, what reaction might we expect? If none, state "none".
Will your student need to take any PERSCRIPTION medications during school hours? Please list.
If yes, please bring all prescription medications to the health office. If none, state "none".
Please sign here if perscription medication will need to be administered at school. I request that a designated member of the school staff administer these medications to my child as listed in accordance with school policy. I also understand that this approval to dispense the agreed upon medications will remain in effect until revoked. To change or revoke the approval, please contact the Health Office at (818) 767-8382 x 240. The electronic signature below and its related fields are treated by Village Christian School as a physical handwritten signature on a paper form.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent/Guardian Name Parent/Guardian Name First Last
Parent contact number
Please add any additional information here: