Health Form 2026-2027

Health Form 2026-2027
Student Name
Grade Level
Gender
Pertinent Family History
Current Health Issues
Allergies
Type of allergy

Other
Type of allergic reaction:

Other
If your child has an anaphylactic reaction for any allergies listed above, please complete the required Food Allergy and Anaphylaxis Emergency Care Plan (FARE) form. This must be completed by your child's pediatrician or allergist. A new form must be completed at the beginning of each school year. In addition, the parent is to supply the school with two forms of Epinephrine (ie...EpiPen, Neffy, Auvi-Q, etc.) that is due by your child's phase-in day.
Preferred response during the school day for allergic reaction:
Inhaler
Asthma
***Please fill out an Inhaler and/or Asthma Action Plan***
Seizures
Please describe:
Diabetes:
Type of Diabetes:
Conditions identified that are important to schooling or physical activity (heart issues, orthopedic concerns, vision problems, recent head injury, bleeding disorder, etc.) Please specify:
Restricted Activity
Physician request to limit
Medication (to be taken and/or available at school) ***Please fill out a Prescription Medication form***
Please list medications to be taken at school:
Over the Counter Medications

The following non-prescription medications may be stocked in the Bright School Health Center and are used on an as-needed basis to manage illness and injury. Please select any medications listed below that your child may be given.
OTC Medications
I authorize the school to obtain emergency medical care for my child in the event of illness or injury during school hours or during a school activity if I cannot be reached. I agree to bear the cost of any medical care provided for my child. This information is kept strictly confidential and will be shared with individuals caring for your child at school.

This information is kept strictly confidential and will be shared with individuals caring for your child at school.
Signature of Parent/Guardian
Parent Printed Name

First NameLast Name
Phone Number

Area CodePhone Number
Date

MonthDayYear
Date
Should be Empty:

Health Form 2026-2027

Current Health Issues

Over the Counter Medications