Health and Emergency Update
This is notification the District may provide your student's vision and hearing screening and personally identifiable information to a Third Party Billing Agent for the purpose of billing Medicaid if you have provided written consent. You may withdraw consent at any time.

We stress the importance of giving the school several options to reach you in case of an emergency. If the phone is disconnected, phone number changed, or job changed - Please notify the school immediately!
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Student's Full Name *
Grade *
Date of birth *
MM
/
DD
/
YYYY
Bus #
Parent/Guardian Name *
Current Health Concerns and/or limitations *
Does the student have diabetes? If so, what is diagnosis date? *
Does the student have significant allergies? If yes, please list those allergies. *
Does the student have seizures? If yes, what is the date of last seizure? *
Does the student have hypoglycemia? If yes, what treatment works best *
Does the student take any asthma medications? What are the student's asthma triggers? *
Does the student have any major illnesses? If yes, please specify. *
Does the student have any other health related issues (physical and/or emotional)? *
Current physician and phone number *
Current dentist and phone number *
Does the student wear glasses? *
Does the student wear contact lenses? *
Parent's email address *
Home phone number
Cell phone number *
Father's Name, work phone number, and place of employment *
Mother's Name, work phone number, and place of employment
 *
Relative's Name, work phone number, and place of employment
 *
Neighbor's Name, work phone number, and place of employment
 *
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