Serious Health Conditions 2023-24
This form needs to be updated annually. Please complete a separate form for each child.
More specific information may be gathered by the school’s health office. Please contact Megan Lapos, School Nurse, prior to the school year: mlapos@marineareaschool.org
If the student rides a bus, the transportation department staff will be responsible for calling 911 if there is an emergency situation on the bus.
Student Name
*
First Name
Last Name
Student/Participant 1 Grade for 2023-24
*
K
1
2
3
4
5
Serious Medical Condition
*
PLEASE LIST
Please give details regarding your student’s health condition and how it may affect their time at school
*
PLEASE DESCRIBE
Current Medications Given at Home
*
PLEASE LIST
Any other conditions the staff should be aware of? (Please check any that apply)
*
VISION
HEARING
ASTHMA
DIABETES
HEART
SEIZURES
LIFE-THREATENING ALLERGIES (please explain below)
Other
If any serious allergies, please explain
Comments and additional information
Physician or specialist name
*
Clinic or hospital name
*
Physician or specialist phone
*
-
Area Code
Phone Number
Parent/Guardian Signature:
Sign and date (if this electronic signature doesn't work for you, please print and sign the hard copy and return to the school office)
Full name used in the signature above
*
Today's Date
-
Month
-
Day
Year
Date Picker Icon
Parent Phone
*
-
Area Code
Phone Number
Parent Email
*
example@example.com
Submit
Should be Empty: