Nurse Clinic Form -- Student Sign-in
Teachers, in an effort to reduce numbers in the clinic and to limit possible exposure to illnesses, please complete this form when needing to send a student to the nurse clinic. The nurse will call for students when she is ready to see them.

In the case of an emergency (seizure, severe head injury, serious bleeding, etc...), bypass this form and bring your student directly to the nurse or radio for the nurse to come to your classroom.

Thank you,
Administration and Nurse
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Email *
Teacher Last Name *
Room Number *
Student Name *
Reason for Clinic Referral (headache, abrasion, stomach pain, etc...) *
A copy of your responses will be emailed to the address you provided.
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