Request Form for District Pupil Health Services
School Year Ending June 2020

The State of Minnesota has authorize local public school districts to allow pupils attending a nonpublic school, (includes home schools), established and operating within the same school district boundaries, access to the existing district Pupil Health Services program. These services must be requested by, or on behalf of, the pupil no later than September 15, 2019.

*Please check "YES". This allows us to accept government funded health services such as our school nurse.

Student First Name *
Your answer
Student Last Name *
Your answer
Grade Level *
Name of School *
Request for Pupil Health Services *
Parent Signature
*
Your answer
*
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