Legacy Christian Academy - Student Medical Form

Student Medical Form 2026/2027

Student First Name

Student Last Name

Birthdate (MM/DD/YYYY)

Name of Parent or Guardian

Address

City

State

Zip

Is the student allergic to anything? If yes, what?

Is the student under a doctor’s care? If yes, why?

Any previous hospitalizations or operations? If yes, please explain.

Is the student on any continuous medication? If yes, what?

Any history of diseases or recurrent illness? If yes, what?

Does the student have any physical disabilities? If yes, please describe.

Does the student have any mental disabilities? If yes, please describe.

Does the student have any neurological or sensory disorders? If yes, please describe.

Please email a copy of the student's most current immunization record to amy@movementchurch.live to complete your application.