Date Updated: 11/6/2017 Student Medical Information

NAME OF CHILD:	Click here to enter text.
DOCTOR:	Click here to enter text.
Address:	Click here to enter text.
Phone:	Click here to enter text.
DENTIST:	Click here to enter text.
Address:	Click here to enter text.
Phone:	Click here to enter text.
INSURANCE:	Click here to enter text.
HOSPITAL:	Click here to enter text.

Does your child have any allergies (drugs, food, insects, grass, pollen, animals, latex etc.)? Yes☐ No☐

If yes, please list: Click here to enter text.

What do you do for a reaction? Click here to enter text.

Does your child have any illnesses or health conditions? Click here to enter text.

Is your child on any medication on a routine basis at home? Click here to enter text.

Will your child be taking any medication during school hours? Click here to enter text.

If so, the medication must be brought by an adult to the school office and a permission slip must be completed by the parent. Students are not permitted to carry medicine with them during the school day. Permission slips for Asthma and Food Allergy Medications are also in the office.

Does your child have any physical disabilities? Click here to enter text.

Does your child have any limitation on activities? Click here to enter text.

Does your child need any special attention because of health problems? Click here to enter text.

Is your child physically able to participate in regular physical education classes? Yes☐ No☐

A written excuse is necessary for a student to be excused from physical education classes.

I acknowledge that this form was completed as honestly and accurately as possible Yes☐

Parent Name: Click here to enter text.

Date: Click here to enter a date.