Health Information Form/ Health Screening Permission

Health Information Form/ Health Screening Permission

Share your health details and relevant medical information accurately.
Student 1 Full Name

First NameLast Name
Student 1 Date of Birth

MonthDayYear
Date
Please check medications YOU GIVE PERMISSION for your child to take at school:
Does your child have permission for a rapid strep test:
Do you have any known allergies?
Current Medications (if any)
Existing Medical Conditions
Health Screening Permission
Throughout the school year, your child may be screened by the school nurse or healthcare professional in the following areas: hearing, vision, weight, height, blood pressure, scoliosis, and dental. The school nurse or healthcare professional will notify you should any of these screening results indicate a concern. If you desire your child NOT to be screened, you must provide that school nurse with written notification. Thank you for being involved in your student's health.
I do NOT want my student to be screened for:
Do you have another student?
Student 2 Full Name

First NameLast Name
Student 2 Date of Birth

MonthDayYear
Date
Please check medications YOU GIVE PERMISSION for Student 2 to take at school:
Does Student 2 have permission for a rapid strep test:
Does Student 2 have any known allergies?
Current Medications (if any) for Student 2
Existing Medical Conditions for Student 2
Health Screening Permission
Throughout the school year, your child may be screened by the school nurse or healthcare professional in the following areas: hearing, vision, weight, height, blood pressure, scoliosis, and dental. The school nurse or healthcare professional will notify you should any of these screening results indicate a concern. If you desire your child NOT to be screened, you must provide that school nurse with written notification. Thank you for being involved in your student's health.
I do NOT want my Student 2 to be screened for:
Do you have another student?
Student 3 Full Name

First NameLast Name
Student 3 Date of Birth

MonthDayYear
Date
Please check medications YOU GIVE PERMISSION for Student 3 to take at school:
Does Student 3 have permission for a rapid strep test:
Does Student 3 have any known allergies?
Current Medications (if any) for Student 3
Existing Medical Conditions for Student 3
Health Screening Permission
Throughout the school year, your child may be screened by the school nurse or healthcare professional in the following areas: hearing, vision, weight, height, blood pressure, scoliosis, and dental. The school nurse or healthcare professional will notify you should any of these screening results indicate a concern. If you desire your child NOT to be screened, you must provide that school nurse with written notification. Thank you for being involved in your student's health.
I do NOT want my Student 3 to be screened for:
Do you have another student?
Student 4 Full Name

First NameLast Name
Student 4 Date of Birth

MonthDayYear
Date
Please check medications YOU GIVE PERMISSION for Student 4 to take at school:
Does Student 4 have permission for a rapid strep test:
Does Student 4 have any known allergies?
Current Medications (if any) for Student 4
Existing Medical Conditions for Student 4
Health Screening Permission
Throughout the school year, your child may be screened by the school nurse or healthcare professional in the following areas: hearing, vision, weight, height, blood pressure, scoliosis, and dental. The school nurse or healthcare professional will notify you should any of these screening results indicate a concern. If you desire your child NOT to be screened, you must provide that school nurse with written notification. Thank you for being involved in your student's health.
I do NOT want my Student 4 to be screened for:
Is there more than 1 parent to sign off on Health Information
Parent 1 Full Name

First NameLast Name
Parent 2 Full Name

First NameLast Name
Parent 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
Date
Parent Signature
Should be Empty: