2023.2024 Oley Valley High School Health Services - Annual Update Form 
For some required responses, "N/A" or "None" may be an applicable answer for your student.
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Email *
Student's Name: *
Student's Birthdate: *
Student's Grade: *
Home Address  *
City *
Zip Code *
Parents/Guardians whom Student lives with:  *
Custody of Student *
Mother/Guardian's Name:
Mother/Guardian's Home Phone:
Mother/Guardian's Cell Phone:
Mother/Guardian's email:
May we email you about health info:
Clear selection
Mother/Guardian's Employer:
Mother/Guardian's Work Phone:
Father/Guardian's Name:
Father/Guardian's Home Phone:
Father/Guardian's Cell Phone:
Father/Guardian's email:
May we email you about health info:
Clear selection
Father/Guardian's Employer:
Father/Guardian's Work Phone:
Please list an alternate contact(s) during daytime hours if parent/guardian cannot be reached: *
Alternate contact(s) phone number: *
Alternate contact(s) relationship to child: *
Please list all children in the family/household and list their grade level if attending school: *
I give my permission for the school nurse or their designee to administer the following medications to my child according to school's standing medication orders (please check appropriate boxes):
Please list any special instructions: *
Health information for this student may be released to school officials, including administrators, teachers, support staff (cafeteria staff, instructional aides), medical consultants or therapists who have a legitimate interest in the student's education and safety.  If you object to this practice, please indicate your wishes: *
Student's Physician's Name: *
Student's Dentist's Name: *
Student's Current Medication: *
Student Health Update SINCE SEPTEMBER OF LAST YEAR
(N/A may be an applicable response to some of the questions below for your Student)
Student wears Glasses or Contacts: *
Student wears a hearing aid: *
Student had a serious illness, surgery, broken bone, or an accident requiring physician's treatment: *
If yes, please explain: *
Student has received any immunizations: *
If your child has received new immunizations in the past calendar year, please provide their school nurse a photocopy of the doctor's record noting the vaccine(s) and date(s) given.
Student had chicken pox disease: *
If selected yes above, please provide date or student's age at time of illness:
Student was diagnosed with a chronic condition: *
If selected yes above, please explain the condition:
Student has Asthma: *
If selected yes above, Student has been prescribed an Inhaler for Asthma: *
Student has ADD/ADHD/ODD: *
Student is prescribed medication for ADD/ADHD/ODD: *
Please list any Allergies Student currently has: *
Student has an Epi-Pen Prescribed: *
Please identify if your Student is under the care of or being followed by a Specialist. *
Please include the name of the Specialist and describe in detail why your student is followed by the Specialist: *
Please provide any additional information which you feel will be helpful.  Also, any questions or problems which you would like to discuss with the nurse or have the nurse discuss with your child: *
If the parents, guardians or alternate contacts cannot be reached in an emergency, I hereby give my permission for the school authorities to use their best judgment in providing the necessary care for this Student, including the sharing of medical information, in order to cope with the immediate problem (please provide your electronic consent by stating your name and today's date): *
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