ST.

JOHN'S COLLEGE JUNIOR COLLEGE

STUDENT HEALTH AND MEDICAL FORM
Student Name: Javier Edgar Simmons
Home Address: 267 Manta Ray Boulevard, Ladyville, Belize
Date of Birth: 2006-11-06 Age: 17 Gender: MALE
In the event of an emergency, notify:
Name: Esela Simmons Relationship: Grandmother Tel: 671-0408
Name: Jennelli Simmons Relationship: Mother Tel: 605-6203

Name of Personal Physician (if any): N/A

Preferred health or medical facility: KHMH
Check ALL items that apply to your health and medical history:
Allergies: Food, medications, insects, plants, other: NO
Explain:
N/A
ADHD Depression/anxiety Panic attacks
Asthma Heart trouble Hypertension
Convulsions/seizures Diabetes Other
Explain:
N/A

List any physical or behavioral condition that may affect school attendance or participation in school related activities.
N/A

I confirm that my son/daughter has disclosed all necessary information regarding his/her medical and health condition as a
student of St. John’s College Junior College. In case of an emergency, I understand that every effort will be made to contact me.
In the event I cannot be reached, I hereby give my permission to the licensed health-care practitioner indicated herein to secure
proper treatment or medication for my son/daughter.

Signature of Parent/Guardian_________________________________________ Date___________________