ST. JOHN'S COLLEGE JUNIOR COLLEGE
STUDENT HEALTH AND MEDICAL FORM
Student Name: Arissa Lorriann Rosado
Home Address: Caye Caulker
Date of Birth: 2006-08-22
Age: 16
Gender: FEMALE
In the event of an emergency, notify:
Name: Lucrecia Burgess
Relationship: Aunt
Tel: 622-7964
Name: Vlada Martinovsky
Relationship: Step-Father
Tel: 614-1643
Name: Shakira Burgess
Relationship: Mother
Tel: 628-0517
Name: Jay Burgess
Relationship: God father
Tel: 631-7060
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___________________