Medical + Exceptionalities Information
PARENT/LEGAL GUARDIAN
This form and the information you provide is optional. The purpose of this information is to help instructors and program staff manage the classroom and does not replace a formal request for learning accommodations. The information you submit is confidential and will be destroyed when your child’s course has ended.
INSTRUCTIONS
- Complete this PDF form.
- Submit via email to [email protected] (Kristina Fiedrich, Programs Manager)
| Student Full Name | Parent / Legal Guardian Full Name |
| Program or Course Name | Start Date |
MEDICAL INFORMATION
Does your child have allergies?
If yes, what are they allergic to: 
Does your child require any medication (including epi-pens)?
Does the medication need to be refrigerated?
If your child carries medication, where is it kept?
PHYSICAL + BEHAVIOUR EXCEPTIONALITIES
Are there any physical or behavioural exceptionalities that we should be aware of to better support your child’s participation in the program? If yes, please describe:
ECU Continuing Studies | Summer 2023