Victory Hill Dorm Medical Information (CF4079)

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Victory Hill Dorm Medical Information (to be completed by a doctor)

The personal information collected on this form will be used for the purpose of service plan and evaluation and will be treated confidentially in compliance with the Freedom of Information and Protection of Privacy Act. Any questions about the  collection, use or disclosure of this information please contact the Director, Provincial Deaf and Hard of Hearing Services at (604) 660-1800 (voice), (604) 660-1807 (TTY), 4334 Victory St, Burnaby BC, V5J 1R2.

Child/Youth

Medical History

Current Medication

Allergies

Other Professionals/Specialists Involved

Use the format A1A 1A1
(555) 555-5555
(555) 555-5555
(555) 555-5555

Immunization Record

Please attach a copy of your child/youth's immunization record.
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4-6 years of age
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
11 year of age (Grade 6)
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
14 year of age (Grade 9)
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
Date of Immunization (MM/DD/YYYY)
Other Vaccinations
Tuberculosis Testing (Required)
MM/DD/YYYY

Signature

Date Signed (MM/DD/YYYY)
Doctors's Signature
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Submission

Click the PDF button to generate a printable version and submit the complete form
Mail to:
Victory Hill Dorm, c/o Patrick Tarchuk
4334 Victory Street
Burnaby BC V5J1R2
 
Please mark the envelope CONFIDENTIAL.
Fax To:
604-660-1859
 
VHD will return a copy of this form to the parent/guardian for their verification and records.
9e41bb01979e503b763a562b75883f2b7977c639
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