GenTechKids

ONLINE CLASSES REGISTER FORM

First Name:

Last Name:

Parent Name:

Email:

Mobile Number:

Boy

Girl

Age:

Birthday:

Country select

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CHILD’S MEDICAL HISTORY

Any concerns about general health (eating and sleeping habits, weight, etc.)?

Any other specific illness or social/emotional or behavioral problems?

Any allergies (food, insects, medication, etc.)?

Any prescription medication (daily or occasionally)?

Any problems with vision, hearing, or speech (glasses, contacts, ear tubes, hearing aids)?

Any hospitalization, operation, or major illness (specify problem)?

Any significant injury or accident (specify problem)?

Any learning disabilities (Autism, ADD/ADHD, Reading issues, Writing issues, Math issues, Dyslexia)