Form 260-3

Health Certification And Parents’/Guardians’ Waiver

# NOTE: You may wish to provide supplemental instructions or make alterations to allow easier usage of forms such as this by ESL Parents.

Student has received the regular immunization program administered in Alberta schools, ie., tetanus and diphtheria, typhoid, smallpox and polio vaccine?     Yes No

In case of emergency, I hereby give permission to the physician selected by the school to provide necessary treatment for my child.

Parent/Guardian Signature: 

Please check the category or extra curricular activities and individual sports below he/she can take part in:

Aquatics Curling Scuba Diving
Can Student Swim? Yes No Cycling Skiing (Alpine)
Badminton Field Hockey Skiing (Cross Country)
Ball Hockey Floor Hockey Soccer
Baseball/Hardball/Softball Football* (Touch or Flag) Track & Field
Basketball Golf Wrestling*
Broomball Hiking Volleyball
Camping Rugby  
Cross Country Running    
All Activities Listed    

*Those with an asterisk must have a doctor’s certificate

Please note any health problems, physical handicap, emotional difficulty, behavioral problem, or facts which may limit full participation in the outdoor program:

PREVIOUS INJURIES: (sprains, strains, fractures, torn muscles, ligament injuries, dislocations)
If yes, check below and describe:

Skull Fracture Upper Arm
  “Knock Outs” or concussions Elbow
Face Injury: Eye Forearm
  Ear Wrist
  Nose Hand
Spine: Neck Pelvis
  Lower Back Hip
  Shoulder Upper Leg
    Lower Leg
    Chest and Ribs
    Abdominal (Stomach)



Student is subject to:

Asthma Ear Ache Fainting
Tonsillitis Eye Infection(s) Sensitive Skin
Sinus Trouble Frequent Colds Nightmares
Bronchitis Sleepwalking Convulsions
Headaches Bed Wetting Kidney Problems
Nosebleeds High Blood Pressure Motion Sickness
Wears Contact Lenses    

Medications: I would like my child to be given:

is in good health to take part in strenuous activities. He/she has my permission to participate in the extra curricular activities and sports indicated above and conducted by:

I/WE also agree with the need to have our son/daughter examined by a physician following an illness or injury to re-establish the bill of good health; this or any other medical examination is my sole responsibility.

(Signature of Parent/Guardian)   (Signature of Parent/Guardian)
Dated:   Dated:
(Signature of Physician)   (Signature of Student)
Dated:   Dated:

Prepared for USIC by: Aon Reed Stenhouse