Health Information

student Name *

First Name Last Name

*

Male Female

student date of birth *

Date Date Picker Icon

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

student grade *

guardian 1 Name *

First Name Last Name

GUARDIAN 1 cell Phone Number *

Area Code Phone Number

GUARDIAN 1 work PHONE NUMBER *

Area Code Phone Number

GUARDIAN 2 Name

First Name Last Name

GUARDIAN 2 cell Phone Number

Area Code Phone Number

GUARDIAN 2 work PHONE NUMBER

Area Code Phone Number

Emergency contact (other than above) *

does student ride the bus: *

Yes No

date of last physical exam? *

Date Date Picker Icon

STUDENT HEALTH INFORMATION

If the following sections don't apply to the student, please select the "None" option or type "None" in the text boxes provided.

medication: list all -prescription, over-the-counter, herbal: *

will medication be needed at school? *

Yes No

If yes, list medication &when needed

**No medication can be given at school without a doctor's order. Please contact the school nurse or school office for appropriate forms.**

School District Office Phone: 719-384-8103

allergies: *

Bees/Insects Latex Nuts Medication Food None

please list allergies Food: Nuts: Medication: Any other allergies. *

what medication does student require for treatment of this allergy? *

EpiPen Benadryl None

Health concerns: *

**If you checked any of the above health concerns, please list any medications, treatments, therapies, activity restrictions, and/or medical equipment that will be need at the school: *

**Have there been any significant changes in your child's health over the last year? Explain: *

Illness/Hospitalizations/Accidents/Injuries: Please list with approximate dates: *

Health care provider: *

Phone Number *

Area Code Phone Number

Dentist: *

Phone Number *

Area Code Phone Number

Please click the link and read the information for the next section of this form.

2019-20 HEALTH INFORMATION

*

I have read and understood the information, and can get more information about Swink School health policies in the Student Handbook, on the school website, or by contacting the school nurse. I give permission for the health information contained on this Health Information Card, to be shared with adults in the school setting who will be working with my child, on a need to know basis. It is the responsibility of the parent/guardian to notify the school nurse whenever there is any change in the student's health status or care.

I give my child permission to use the sunscreen I have provided for them when it is needed during school activities. *

Yes No

I give permission for my child to be screened for hearing, vision, height and weight *

Yes No

Signature of Parent/ Guardian completing this form *

Clear

office use only

Snap