Student Health History & Medical Information 2018-2019
This information is needed to care for your child in case of illness or injury and to meet your child's health needs at school. If your child needs medication at school, a licensed physician must complete our Administration of Medication form. Medication and form should be turned in to the front office. Students are not allowed to carry medication to the classroom.
The information contained in this form is confidential as provided by federal law, the Family Education Rights and Privacy Act, FERPA, 20 USC 1232g and state law. Only those school employees with a good educational reason may access and inspect this form. In a health related emergency, emergency personnel may be granted access to the information on this form.
Email address *
Student Last Name *
Your answer
Student First Name *
Your answer
Student Grade *
Date of birth *
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Parent/Guardian Name *
Your answer
Emergency contact phone numbers *
Your answer
Where does your child receive health care? (Please list name and phone number) *
Your answer
Date of last physical exam *
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DD
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YYYY
Does your child have any of the following: *
Required
Please give us a brief explanation for the boxes checked above (or write N/A) *
Your answer
Does your child have emergency medication that needs to be kept at school (epi-pen, inhaler, seizure medication, etc) *
Does your child need to take medication during school hours? (OTC or prescription) ***An administration of medication form will need to be filled out by a licensed physician*** *
Please list all emergency medications and/or OTC and prescription medications that need to be stored at the school (or write "none" *
Your answer
Has your child experienced a head injury of any kind in the past year? (e.g. concussion) *
Any other health problems we need to be aware of? (or write "none") *
Your answer
Was your child hospitalized or did your child have major health changes within the past year? explain or write "no" *
Your answer
By checking the box below, I attest that I am the parent and/or legal guardian of the child *
Required
Parent Electronic Signature: *
Your answer
A copy of your responses will be emailed to the address you provided.
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