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2020-2021 Health Entrance Form

Please complete the form below. Required fields marked with an asterisk *

The parent or gaurdian completes this page. This form must be completed prior to the beginning of each school year for each student. 

Entering Grade*
Answer Required
Does your child qualify for nutrition assistance (free or reduced lunch pricing)?*
Answer Required
Please indicate if you child has any of the below conditions. If you answer "yes" to any of these conditions, please explain in the box below.*
Answer Required
No
Yes
Allergies - Life Treatening
Allergies - Non-Life Threatening
Anxiety
Austism/Asperger's
Asthma/Breathing Problems
Bipolar
Bleeding problems
Cerebral Palsy
Depression
Diabetes
Headaches (including migraine)
Heart problems
Nutritional/Growth issues
Speech problems
Behavior issues
Eating Disorder Issue
ADD/ADHD
Seizures/neurological
Stomach problems
Bladder/bowel problems
Cystic fibrosis
Dental problems
Developmental Delay
Head injury, concussions
Muscle/Orthopedic problems
Other (please explain in box below)
Vision and Hearing problems:*
Answer Required
No
Yes
Glasses/Contacts worn
Hearing aides worn
Hearing loss
Preferential Seating needed
Would you like to discuss confidential information with the school nurse?
Answer Required

By typing my name and date in the box below, I acknowledge that I have voluntarily provided this health information to my child's school and understand that it is confidential and is only shared with staff on a need to know basis.

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