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2021-2022 Health Entrance Form

Health Information:

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
Yes
No
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)
Please indicate if your student has/had any of the following supports/interventions*
Answer Required
Yes - Current
Yes - Past
No
Individualized Education Plan (IEP)
Advanced Learning Plan (ALP)
504 Plan
READ Act (Reading Intervention) Plan
English Language Development Plan (for ELL/ESL students)
Medical Plan
Vision and Hearing problems:*
Answer Required
Yes
No
Glasses/Contacts worn
Hearing aides worn
Hearing loss
Preferential Seating needed

I give permission for AXIS staff to call a doctor, ambulance, hospital, or for a member of staff to transport my child should a medical emergency arise. It is understood that a conscious effort will be made to contact me before any action will be taken, but if not possible the expense of the medical care will be accepted by me, student's parent / guardian.

I accept and agree to the above statement.*
Answer Required
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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