JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Consent for Treatment for School Nurse (2025-2026 School Year)
Please complete the following form for each student in order for your child to see the school nurse for the 2025-2026 school year
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student's Grade Level
*
TK/K
1
2
3
4
5
6
7
8
9
10
11
12
Preschool/GSRP
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Does this student have any of the following?
*
Medication Allergies
Seasonal Allergies
Food Allergies
Sting Allergies
Asthma (Please explain in the next question what the asthma is triggered by)
Diabetes (Please explain in the next question what the desired blood sugar levels are)
Epilepsy/Seizure Disorder (In the next question, please give the last seizure date & describe the last seizure)
Heart Conditions
Mental Health Issues or Disorders
Wears Glasses
Have Contact Lenses
Tubes in Ears
Frequent Ear Infections
Hearing Aids
Difficulty Hearing
ADD/ADHD
Birth Defects
Bladder/Bowel Problems
Blood Pressure Problems
Bleeding Disorders
Headaches (Please explain in the next question the best treatment for their headache)
Menstruation Problems
Nosebleeds
Skin Problems
Sleeping Problems
NONE
Required
Please inform us of any conditions or accommodations needed to help this student.
Please also provide any explanations asked after conditions so our nurse can better help this student.
Your answer
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Homerschools.net.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
