Medication & Health Record
Is your child on allegy injections?
Does you child use an inhaler?
Does you child have Asthma?
Does you child have a specific Asthma Action Plan?
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Who is responsible for giving you child's asthma medication at home?
On a scale of 0-10, how bad (severe) has your child's asthma been over the last year? (10 Being Severe/Choose One Only).
Is your child allergic to any MEDICATION (penicillin, sulfa, etc.)?
Is your child allergic to any FOODS?
Is your child allergic to any ANIMALS?
Is your child allergic to any INSECTS?
Was emergency treatment needed for any of the reactions listed above (ex. 911, ER Visit, Urgent Care, EpiPen)?

Specifically, does you child have any of the following?

Convulsive Disorders?
Discipline Problems?
Heart Disease?
Attention Deficit Disorder?
Learning Disability?
Obsessive Compulsive Disorder?
DPT, Polio, and MMR immunizations up-to-date?
Are there any other medical problems or conditions your child ha that the school should know about?
Has your child ever been away from home and parents?
Does your child feel embarassed at school or in public if they have to take an inhaler?
Do you anticipate any activity restrictions?
Are there any present physical education restrictions at school?
Is there any else you feel school staff should know about your child?



In consideration for being allowed to register and participate in school, held in the school year entered below, sponsored by Echelon Academy, as parent/guardian I hereby release the Association, its Incorporators, Physicians, Board Members, Officers, Employees, Agents, Independent Contractors and Volunteer Workers from any liability for injuries which are sustained during the school, including any necessary transportation. The child herein described has permission to engage in all scheduled activities except as noted by the physician or parent/guardian. I hereby give permission to the school to initiate and provide any necessary treatments, including transporting to the nearest certified emergency facility. If hospitalization is required, the child is to be referred to an appropriate physician and all treatments will be at my expense.

Your Signature

Echelon Academy Burtonsville, MD

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4032 Blackburn Lane

Burtonsville, MD 20866

Echelon Academy is a K-12 private school in Montgomery County, Maryland.

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Echelon admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school.  It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.