Medical Form

Please attach medical records as required.

Name*
Date of birth*
Health card no.*

Emergency Contact

Emergency contact name*
relationship to patient*

Emergency Contact Number*

Medical History

Does the applicant carry an EPI-PEN?
Explain the emergency plan as provided by medical professional.*
Is the applicant currently under medical treatment? or taking any medications?
Current Medications

Please list any medications you are currently taking.

Medication
Strength
Dose
Will the student require prescription medication to be taken at the school?
Current Medications

Please list any medications you are currently taking.

Medication
Strength
Dose
I _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​give consent to Darul Uloom Canada to administer medication.
Signature
Provide the name of the applicant's primary doctor:*
Doctor's Phone No.*
Does the applicant have any known allergies?*
Please list allergies:*
Check all current and past conditions:
Please explain the above conditions selected as needed.*
Permission Waiver

By submitting this document, I certify that all information is accurate. I give permission to Darul Uloom Canada to contact 911 for medical attention as required, release the above contact and medical information.

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Please fill out the admission form or contact us for any enquiries.

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