2022-23 Health Form

STUDENT HEALTH INFORMATION

2022-23
Student Last Name *
Student First Name *
Student Middle Name/ Initial
Grade *
Gender *

Male Female
Date of Birth *

Month Day Year
Date
EMERGENCY CONTACT INFORMATION
Emergency Contact #1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to student *
Emergency Contact #2 *

First Name Last Name
Phone Number *

Area Code Phone Number
Student's Primary Physician

First Name Last Name
Primary Phone Number

Area Code Phone Number
Does your child have any allergies (food, medication, other)? *

Yes No
If "Yes", please explain your child's allergies. *
Please type N/A if this does not apply
Does your child have any specific health needs or chronic health conditions? *

Yes No
If "Yes" please explain your child's special health need or chronic condition? *
Please type N/A if this does not apply
Medications child takes for this condition *
Please type N/A if this does not apply
Side effects child may experience from mediciation
Comments/ Things we should know
If an emergency arises requiring treatment for your child, every effort will be made to contact you immediately. In the event of a life-threatening situation 911 will be called. Doctors and hospitals are very conscious of liability suits and will not treat a child without parental consent. Your signature gives us authority to seek emergency medical treatment. DuBois Integrity Academy assumes no financial responsibility for actions taken to provide emergency medical services for you child.

By signing below the parent/ guardian gives the DIA school health program permission to assess, evaluate and manage a student's sudden illness and medical conditions while at school or a school event.
Parent/Guardian Signature *

Clear
Should be Empty:

STUDENT HEALTH INFORMATION

EMERGENCY CONTACT INFORMATION