Health Records Form

This form is available when pre-registering students for the school year and only needs to be filled out for new students or when something needs updated. You can not include multiple children on the same form submission.

Student Name

First Last

Home Address

Street Address Address Line 2 City State ZIP Code

Age

Date of Birth

Sex

Male

Female

School

Parent / Guardian Name

First Last

Phone

Chickenpox

Give approximate date

Pneumonia

Give approximate date

Asthma

Give approximate date

Operations

Allergies

Other frequent health problems

IMMUNIZATION DATES PROVIDED BY PHYSICIAN OR CHIRP REPORT:

Varicella (Chicken Pox) #1

Varicella (Chicken Pox) #2

DTaP (Diphtheria-Tetanus and Pertussis) #1

DTaP (Diphtheria-Tetanus and Pertussis) #2

DTaP (Diphtheria-Tetanus and Pertussis) #3

Polio (IPV) #1

Polio (IPV) #2

Polio (IPV) #3

Polio (IPV) #4

MMR (Measles, Mumps & Rubella) #1

MMR (Measles, Mumps & Rubella) #2

Hepatitis B #1

Hepatitis B #2

Hepatitis B #3

Hepatitis A #1

Hepatitis A #2

Boosters for 6-8th Grade

Tdap (Tetanus & Pertussis)

MCV4 (Meningitis)