Health Information

Health Information
student Name*

First NameLast Name
MaleFemale
student date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
student grade*
guardian 1 Name*

First NameLast Name
GUARDIAN 1 cell Phone Number*

Area CodePhone Number
GUARDIAN 1 work PHONE NUMBER*

Area CodePhone Number
GUARDIAN 2 Name

First NameLast Name
GUARDIAN 2 cell Phone Number

Area CodePhone Number
GUARDIAN 2 work PHONE NUMBER

Area CodePhone Number
Emergency contact (other than above)*
does student ride the bus:*

YesNo
date of last physical exam?*

MonthDayYear
Date
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?*

YesNo
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/InsectsLatexNutsMedicationFoodNone
please list allergies Food: Nuts: Medication: Any other allergies. *
what medication does student require for treatment of this allergy?*

EpiPenBenadrylNoneOther
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 CodePhone Number
Dentist:*
Phone Number*

Area CodePhone 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.*

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

YesNo
Signature of Parent/ Guardian completing this form*

Clear
office use only

Snap
Should be Empty: