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Section 1 of 4
Student Health Form
This form must be completed for each student attending school at Wonewoc-Center School District for the 2025/2026 school year. It will be reviewed by the School Nurse. Information may be provided to your student's teacher or appropriate school personnel for the care of your child.
Student Name
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Date of Birth
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Grade
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Section 2 of 4
Medical Conditions
Please select any medical conditions that your student has. If your student has no known medical conditions, you may skip this step.
Select any medical conditions this student has
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ADD/ADHD
Allergy - Severe Anaphylactic/Life Threatening (food, stings, latex)
Allergies (seasonal, environmental, non life threatening)
Asthma
Diabetes
Seizure Disorder
Anxiety
Depression
Migraine Headaches
Vision or Hearing Impaired (Different than glasses, contacts)
Gastrointestinal (ie: Chron's Disease, Lactose Intolerance, IBS)
Autism
Genetic Disorder/Syndrome
Neurological/Brain Injury
Scoliosis
Heart Condition
Other:
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Please explain any of the above checked health conditions and how the condition(s) affect your child
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Please list any medications that your child takes including name of medication, dose taken, and time taken.
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Section 3 of 4
Over the Counter Medications
Listed below are the Over the Counter (OTC) Medications that the nurse has available in the School Health Office for students on an as needed basis. We hope that using these medications, as needed, will reduce absenteeism, and allow students to continue to participate in class in certain situations. If a student needs routine medication, or begins requesting these medications on a regular basis, parents will be asked to make arrangements to provide medication for their student's needs. Please note- NO CHEWABLE forms are available- parents must provide these if needed.

All OTC medications will be administered based on package age/weight dosing guidelines.

If you do not wish to authorize OTC medications for your student, you may skip this step.
Please select which medications you authorize the Wonewoc-Center School Nurse or designated staff to administer on an as needed basis:
Question Type
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Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Antacid (Tums)
Antibacterial Ointment
Cough Drops
Anti-itch cream/hydrocortisone
Lubricating Eye Drops
Aloe Gel
Diphenhydramine (Benadryl) - only for use in the event of an allergic reaction
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Section 4 of 4
Parent/Guardian Consent
If your student has a medical condition listed above, the School Nurse may contact you to review their condition and develop an Emergency Action Plan for your student. If there are any other health related concerns that you would like the school to be aware of, please contact the School Nurse by emailing: weldjod@wc.k12.wi.us, or calling 608-464-3165 ext 131.

By typing my name below and submitting this form, I acknowledge that this will be used as my signature for this form and I hereby give permission and authorize the Wonewoc-Center School District Staff to administer the above selected OTC Medication(s) based on package/weight dosing guidelines and release the district and employees from any liability claims as a result of the administration of the above selected medications.
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Date
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Student Name
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Date of Birth
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Grade
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Medical Conditions
Select any medical conditions this student has
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Please explain any of the above checked health conditions and how the condition(s) affect your child
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Please list any medications that your child takes including name of medication, dose taken, and time taken.
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Over the Counter Medications
Please select which medications you authorize the Wonewoc-Center School Nurse or designated staff to administer on an as needed basis:
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Parent/Guardian Consent
Parent/Guardian Name
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