NEW STUDENT HEALTH FROM (First time enrollment at West Marshall)

Name of Student:*

First Last

Student Grade Level*

Previous Health Concerns*

Please check all that apply. If other please contact our nurse. Thank you

Please list any current or ongoing medications taken-(IF NONE LEAVE BLANK)

Does your child have any FOOD ALLERGIES?*

If you selected YES, please describe allergies your child has. (IF NO LEAVE BLANK)

Does you child have and EPI PEN to use due to an anaphylactic allergic response?*

May we share your child's health concerns with their assigned classroom teacher?*

Only if the concerns are relative to learning in the classroom.

Does you child have health insurance?*

Would you like information regarding Hawk-i insurance?*

If the parent/guardian and emergency contacts can not be reached, DO YOU AUTHORIZE the school to contact medical attention local health clinic or calling 911?*

Name of parent/guardian completing this survey:*

The person listed is a parent/guardian who is responsible for the primary care of the child.

NEW STUDENT HEALTH FROM (First time enrollment at West Marshall)

NEW STUDENT (to the district) HEALTH FORM