Health and 504/Special Education Form 2019-20
Please fill this out if your student has even received special education services and if they have a health issue so we can add it to your student's profile.
Your First and Last Name
Your Student's First and Last Name?
Has your student even been on an IEP or 504 (also known as special education or resource)
Yes but not in the last year
Please mark any health issues your student has that we should know about.
Life threatening allergy (List allergy under other)
Chronic condition (List condition under other)
Allergy to medications (List allergy under other)
Mental Health Related Issues
Medication taken at home or school for emergency reference.
Do you currently have health insurance or medical coverage? If not, you may call 1-877-543-7669 for information about CHIP (Children's Health Insurance Program) or Medicaid.
Do you give permission for us to share this health information with school personnel who have a need to know your child's health concerns such as their teacher and office staff?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Itineris Early College High School.
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