PRHS Summer Health Update

2020-2021
Parents/Guardians:

Please complete the following information and submit electronically as soon as possible so we can ensure your child's needs are met in the school setting and update our health records.

Email address *
Email address *
Name of the Parent/Guardian Completing this Form: *
Student's Last Name *
Student's First Name *
Grade *
During the past year, has your child had a serious injury? *
If Yes, please explain
During the past year, has your child had a serious illness? *
If Yes, please explain
During the past year, has your child had any surgeries? *
If yes, please explain
During the past year, has your child had an allergic reaction? *
If Yes, please explain
Please list current medications *
Does your child have any activity restrictions (physical education, sports, recess)? Please note if there are any restrictions you must supply us with a current note from a medical doctor stating the reason and duration of the restriction. *
If yes, please explain
Electronic Signature Parent/Legal Guardian *
Submit
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