Student Health Information Form, District
It is important that the school be made aware of any health concerns or problems that may affect your son or daughter's ability to learn.
Please complete the information below and submit. This information will be reviewed by the school nurse and be a part of your child's confidential health record. Health information pertinent to school activities will be shared with faculty directly involved with your son or daughter.
If you would like to discuss any concerns about your student's health with the school nurse, contact the school office for an appointment.
Thank you for your cooperation.
Student LAST Name
Student FIRST Name, Middle Initial
Date of Birth
Did your child ever have or does your child now have:
Bone, Joint or Muscle Problems
Attention Deficit Disorder
Frequent Colds or Sore Throats
Alcohol/Other Drug Abuse
Tumors, Growths, Cysts, Cancer
If you checked any of the above, please explain:
Are there any special emergency instructions or any other health problems or family matters which you think would be helpful for the school to know?
Does child take routine medication? If so, give type, amount and reason.
Do you know of any reason to limit your child's physical activities? If so, give explanation.
Has your child had any severe reactions/allergies to drugs, foods, or bites & stings? If so, give explanation.
Parent Signature. By submitting you are signing this Agreement electronically.
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