NORTH CAROLINA CONFERENCE OF TEMPLES AND COURTS

Ancient Egyptian Arabic Order Nobles Mystic Shrine

Of North and South America and Its Jurisdictions, Inc.

MEDICAL HISTORY

Allergies ___________________________________________________________________

Past Illnesses________________________________________________________________

Is the child healthy and able to march in hot weather during a Convention parade or any parade

of length? Yes No

Is the child now on any type of medication? Yes No If yes, list below __________________________________________________________________________

Does the child have any type of health defects? Such as wearing glasses, etc?

Has the child been treated for:

¨ Bleeding

¨ Convulsions

¨ Heart Trouble

¨ Hypertension

¨ Lung Disease

¨ Muscle Joint

¨ Diabetes

¨ Kidney

¨ Epilepsy Other (Specify)

¨ Previous Hospitalization ___________________________________________________

My permission is given to any qualified Physician or emergency room physician to treat my child.

The above information is true and accurate.

Signature _____________________________________________

(Parent(s) or Guardian)