Fillable Massachusetts State Police Academy - Medical Questionnaire

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Massachusetts State Police Academy - Medical Questionnaire

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The Massachusetts State Police Academy - Medical Questionnaire form is 2 pages long and contains:

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  • 4 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Commonwealth of Massachusetts
Massachusetts State Police Academy
Student Trooper Program
Medical Status Questionnaire
Student Name: ___________________________________ DOB: ____/_____/____
Address: _____________________________________ City/Town: ________________________
State: ________ Zip Code: ______________ Home Phone: (_______) ______________________
Emergency Contact Person: ________________________________________________________
Relationship: __________________ Telephone: Home: (_______) ______________________
Cell ___________________________ Work: (_______) _______________________
Health Insurance: Yes No Company: ________________________________________
Policy # ________________________ Telephone: (_______) ________________________
Brief Medical History: (list injuries past and present)
Allergies:
Yes No (If yes, please identify)
List all medications (both over the counter and prescribed medications) taken:
TWO SIDED FORM – SEE REVERSE SIDE
PARENT SIGNATURE REQUIRED ON REVERSE SIDE
Medical Questionnaire Form – Page 1
1
Medical Questionnaire Form – Page 2
2
I __
__________________________ parent/guardian of _____________________________
(PRINT) (PRINT)
state that the information
contained on this form is true to the best of my knowledge.
I give permission to the members of the Massachusetts State Police Academy Health Unit to
dispense any over the counter medication and/or prescribed medication to the above Student
Trooper. Please be advised that all medications brought to the Massachusetts State Police
Academy must be in it's original packaging including over the counter medicine and a pharmacy
label must be on all prescribed medications.
I give permission to members of the Massachusetts State Police Academy staff and/or
Health Unit
to provide initial medical treatment and in the case of an emergency to have the above Student
Trooper transported to the nearest medical facility and treated by a physician.
__________________________
____________________________
______________
(Print Paren t/Guardian Nam e)
(Parent/Guardian Sign ature)
(Date)
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Massachusetts State Police Academy - Medical Questionnaire

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Completed 11 May 2020

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