Student Health History Form

Date REQUIRED Please fill out this field. Please enter a date.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Incoming Grade REQUIRED Please fill out this field.

Birth Date REQUIRED Please fill out this field. Please enter a date.

Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.

Parent/Guardian Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number REQUIRED Please fill out this field. Please enter a phone number.

List of Daily Meds Given

Reason for Meds Please enter valid data.

Student Allergy History REQUIRED Please fill out this field.

Allergies Animals Drugs Environmental Foods Bees/Wasps

Name of Allergen, Describe Reaction, and Treatment

Provide additional information for conditions checked. Include dates, ages, treatments, ongoing care, etc.

Select Number of Parents/Guardians REQUIRED
By typing my/our names and checking the 'I Agree' boxes on this form, I/We verify this serves as an electronic verification and signature.
Please fill out this field.
Parent/Guardian 1
- First & Last Name Please enter valid data.
Parent/Guardian 2
- First & Last Name Please enter valid data.

I, parent/guardian attest that the information provided is accurate and current for the listed student.

I Agree Please select this field.

Please Submit a Form for Each Student