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Student Health Form
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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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Date
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