Medical Questionnaire

Save & Return (optional)

New Users and Returning Users should CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form. You will need to set up a new account for each form that has Save & Return.

Medical Questionnaire for New Students
To be completed no later than July 15, 2018

To the Parents:

Please complete this form carefully, being very thorough and specific. For your student's health and safety, it is important that we have complete knowledge of ALL past and present medical conditions and treatments. This information is strictly for the use of the American Hebrew Academy Student Health Center.

Student's First Name *

Middle Name

Last Name *

Email Address

Year of Graduation *

Student's Date of Birth * +

Student's Cell #

Gender *

Male

Female

Family Information

Best Phone Number to reach Parent/Guardian *

Parent Email * 🛈

Contact person if parents are unreachable *

Phone # *

Parents are:

Married

Divorced

Separated

If parents are living apart:

With whom does the student live?

Who is the legal guardian?