Mosinee HS Health Form 2018-19
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Fill in the Student Information below
Student's Last Name:
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Student's First Name:
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Field Trip and Medical Emergency Authorization
Any information you feel the district should be aware of in regard to custody arrangements or emergency contacts.
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Please check ALL the medications that the school may give:
Each time your child recieves medication, he/she will be given a note stating when and what was administered. By checking the boxes below, you give permission for the following medications to be given to your son/daughter in the Health Room.
Please check if your child has
(check ALL that apply)
Please explain any of the above conditions and list any medications student takes at home that are not listed above.
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