Elevator Pass Update Form

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Please take a few moments to answer the following questions.
Your answers will be used to create an individualized school healthcare plan for your child.
Also, information will be shared on a need to know basis with school personnel for health, safety and educational purposes.

Email *

Student's Legal Name (last, first) *

Student Graduation Year *

Student's Date of Birth *

YYYY

Current Medical Diagnosis... *

Is your child able to participate in the required PE program? *

Yes- without accommodations

No- a written doctor excuse note is required every school year.

Yes- with accommodations (please list under Other option)

Other:

Does your child need permission to use the school elevator? *

Yes

Maybe

Other:

Does your child assistance leaving the building during an emergency situation? *

Yes

Maybe

Other:

Does your child need any special health accommodations to be successful in the school setting? *

Yes

Maybe

Other:

List doctor name and number who can verify above noted health information. *

Name of parent/person completing this form... *

Submit

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