School Physical Clinics  June, 2023
Please complete this form if you have a child(ren) planning to come to a JCPS physical/immunization 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 as well, 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.  
Sign in to Google to save your progress. Learn more
Email *
Last Name of Student who Will Have a Sports or School Physical

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

Student's Birthday

Name of parent or caregiver (for Student)

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? *
Where has your child received their vaccinations in the past (please list the names of provider offices) *
In order to make sure your child's records are current and accurate, immunization records should be updated in the Kentucky Immunization Registry.  May we update your child's records in the Registry where you will be able to access a copy of the records?   *
For those students having sports physicals: please click the links below to see what forms the coaching staff will have access to when the physical is complete. Other health records will be uploaded to the student's Electronic Health Record and will be kept confidential.

Forms that Schools & Coaches will have access to- English
Which Physical Location/Date do you want your Child to Attend?
Clear selection
Please list any additional questions here so that staff can respond: 
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jefferson County Public Schools. Report Abuse