Student Health Information Form, District
Dear Parent,
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 *
Your answer
Student FIRST Name, Middle Initial *
Your answer
Date of Birth *
MM
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DD
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YYYY
Grade *
Did your child ever have or does your child now have:
If you checked any of the above, please explain:
Your answer
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?
Your answer
Does child take routine medication? If so, give type, amount and reason.
Your answer
Do you know of any reason to limit your child's physical activities? If so, give explanation.
Your answer
Has your child had any severe reactions/allergies to drugs, foods, or bites & stings? If so, give explanation.
Your answer
Parent Signature. By submitting you are signing this Agreement electronically. *
Your answer
Date *
MM
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DD
/
YYYY
Home Phone
Your answer
Work Phone
Your answer
Submit
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