Allergy and Medical Information

Mission:

Through engaged and interactive learning, Back to the Basics Tutoring LLC aims to help increase the knowledge of basic foundational concepts

Vision:

Back to the Basics Tutoring LLC aims to inspire and motivate children to excel academically through engaged and interactive learning by using new approaches to increase their focus and participation in a learning environment. To help develop the children's needs and also build a partnership with parents, families, and communities to best help the children to build their progress and confidence in identified academic areas.

Fill out this form completely and accurately. This form helps ensure we are aware of relevant medical information so that we are able to address any situations that may arise during the program.

Child's Information

Child's Name

Parent/legal guardian name

Allergies

Is your child allergic to any medication, food, etc.? What is the severity of their allergy? What should be done in case of a reaction? (EpiPen, inhaler, etc.)

Medical Conditions

Does your child suffer from any pre-existing medical conditions (seizures, diabetes, mental health issues, eating disorders, etc.)? What are the warning signs that we should be aware of, and what should be done in case of emergency?

Prescription Medication

Does your child take any prescription medications? If so, please list prescriptions and dosage information. (In case of n emergency, we can give the correct information to authorities.)

Any Other Information

Is there any other information about your child's health or medical history that we should know prior to the start of the program?

Parent/Guardian Signature

Select a date

I agree to be contacted by Back to the Basics Tutoring via texts, calls and emails. To Opt-out reply 'stop' at anytime or click the unsubcribe link in the emails. Message and data rates may apply.

Thanks for submitting!

Additional Questions?

Contact Kiyana Mensah

Phone: 414-973-1009

Email: Bck2thebasicstutoring18@gmail.com

If you would prefer, you may download the document below and email the completed document to bck2thebasicstutoring18@gmail.com

Download Document