LOA Student Medical Information 
Please complete this form regarding your student's medical history, allergies, medication use, and consent for  treatment.  

A form must be completed for each student within a household. 

There will no longer be a hard copy of the medication form. 

Please contact, Jessica Tolbert, LOA's school nurse for any questions or concerns at jessica.tolbert@lakeoconeeacademy.org.
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School Year *
Student's First Name *
Student's Last Name *
Student's Date of Birth *
MM
/
DD
/
YYYY
Grade *
Allergies *
 For serious allergies, please provide an Allergy Action Plan.  PLEASE INDICATE SPECIFIC ALLERGY IN "OTHER" SECTION BELOW. 
Required
Allergy Reaction(s) *
Required
Current Medications Taking at Home: Please List All
Hearing or Vision Impairment *
Required
Doctor's Name and Phone Number
Current Medical Conditions *
Please describe in detail the issues you selected below in the "OTHER" section.  
Required
My signature below grants the school nurse permission to share medical information with EMS and/or school personnel/Greene County School System (administrators, teachers, nurses, support staff, and supervisory officers) as necessary to ensure my child's safety and well being. This permission also permits the school nurse to contact my child's physician for further information if necessary for the health and welfare of my child while on campus at Lake Oconee Academy. 

The collection of this information is under the Authority of the Education Act & Regulations for the purpose of maintaining student records. 

I hereby certify that this information herein is correct to the best of my knowledge.

Parent/Guardian's Name and Date 
 *
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