JCPS Health & Wellness Physical Clinics  June, 2024
Please complete this form if you have a child(ren) planning to come to a JCPS physical clinic. This information will be used to help speed the process through clinic on the day they come. Fill out a form for each child attending.  Please note that for sports physicals, the coaches or athletic trainers will be sending home forms that should be completed and signed by parents or legal guardians.
For those student's having school physicals, we will send home the required paperwork that should be completed by a parent/guardian.  
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Email *
Last Name of Student who Will Have a Sports or School Physical

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First Name of Student who Will Have a Sports or School Physical


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Student's Birthday


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Name of parent or caregiver (for Student)

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Best contact number for parent or caregiver for Student *
What is the name of the  school the student attended for the 2022-2023 school year? *
Is your child current on routine immunizations?
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Where has your child received their vaccinations in the past (please list the names of provider offices) *
IF you are planning to attend a clinic the last two weeks in June for a Sports Physical- do you have a paper copy of the required forms? Or would you like an electronic copy be sent to you to complete over your computer or phone? *
If you want forms sent electronically, what is the best email address to use?
Which Physical Location/Date do you want your Child to Attend?
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Please list any additional questions in the spaces below
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