2023-2024 Confidential Medical Information Student's Name (1)(Required)
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(1) is for the first student when filling this application for more than one student.
Allergy To Ants(Required) Allergy To Wasps(Required) Allergy To Bee Stings(Required) Specify Reaction To Allergy or Allergen(Required) Does Student Have Asthma? If Yes, Age of diagnosis, Is student currently under Doctor's care?, What are triggers?(Required)
Does Student Have Attention Deficit/Hyperactivity Disorder (ADD/ADHD)? If Yes, Do they take medication? If so, what medication(s)?(Required)
Does student have Autism Spectrum Disorder?(Required) Diagnosed by Medical Doctor?(Required) Blood Disorder?(Required) Sickle Cell Anemia?(Required) Cancer? Explain:(Required)
Cardiac Heart Condition? Explain:(Required)
Cystic Fibrosis? If Yes, Name of medication if taking any:(Required)
Diabetes?(Required) Does student require insulin at school?(Required) Does student have Hypoglycemia?(Required) Does student have a Mental Health Condition?(Required) Does student have any other Medical condition not listed above? Explain:(Required)
Mark N/A if not applicable
Other medication(s) taken not listed above:(Required)
Mark N/A if not applicable
This student doesn't have any conditions or illnesses(Required) Does your student have insurance coverage? If yes, what insurance(s) names? (Private, Medicare, etc.)
(2) Student Two (2) is for the second student when filling this application for more than one student.
(2) Second Student's Name(Required)
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(2) Allergy To Ants(Required) (2) Allergy To Wasps(Required) (2) Allergy To Bee Stings(Required) Specify Reaction To Allergy or Allergen(Required) Does Student Have Asthma? If Yes, Age of diagnosis, Is student currently under Doctor's care?, What are triggers?(Required)
Does Student Have Attention Deficit/Hyperactivity Disorder (ADD/ADHD)? If Yes, Do they take medication? If so, what medication(s)?(Required)
Does student have Autism Spectrum Disorder?(Required) Diagnosed by Medical Doctor?(Required) Blood Disorder?(Required) Sickle Cell Anemia?(Required) Cancer? Explain(Required)
Cardiac Heart Condition? Explain(Required)
Cystic Fibrosis? If Yes, Name of medication if taking any(Required)
Diabetes?(Required) Does student require insulin at school?(Required) Does student have Hypoglycemia?(Required) Does student have a Mental Health Condition?(Required) Does student have any other Medical condition not listed above? Explain:(Required)
Other medication(s) taken not listed above:(Required)
This student doesn't have any conditions or illnesses(Required) Does your student have insurance coverage? If yes, what insurance(s) names? (Private, Medicare, etc.)(Required)
(3) Student Three (2) is for the third student when filling this application for more than one student.
(3) Third Student's Name(Required)
First
Last
Suffix
Allergy To Ants(Required) Allergy To Wasps(Required) Allergy To Bee Stings(Required) Specify Reaction To Allergy or Allergen(Required) Does Student Have Asthma? If Yes, Age of diagnosis, Is student currently under Doctor's care?, What are triggers?(Required)
Does Student Have Attention Deficit/Hyperactivity Disorder (ADD/ADHD)? If Yes, Do they take medication? If so, what medication(s)?(Required)
Does student have Autism Spectrum Disorder?(Required) Diagnosed by Medical Doctor?(Required) Blood Disorder?(Required) Sickle Cell Anemia?(Required) Cancer? Explain:(Required)
Cardiac Heart Condition? Explain:(Required)
Cystic Fibrosis? If Yes, Name of medication if taking any:(Required)
Diabetes?(Required) Does student require insulin at school?(Required) Does student have Hypoglycemia?(Required) Does student have a Mental Health Condition?(Required) Does student have any other Medical condition not listed above? Explain:(Required)
Mark N/A if not applicable
Other medication(s) taken not listed above:(Required)
Mark N/A if not applicable
This student doesn't have any conditions or illnesses(Required) Does your student have insurance coverage? If yes, what insurance(s) names? (Private, Medicare, etc.)(Required)
(4) Student Four (4) is for the fourth student when filling this application for more than one student.
(4) Fourth Student's Name(Required)
First
Last
Suffix
Allergy To Ants(Required) Allergy To Wasps(Required) Allergy To Bee Stings(Required) Specify Reaction To Allergy or Allergen(Required) Does Student Have Asthma? If Yes, Age of diagnosis, Is student currently under Doctor's care?, What are triggers?(Required)
Does Student Have Attention Deficit/Hyperactivity Disorder (ADD/ADHD)? If Yes, Do they take medication? If so, what medication(s)?(Required)
Does student have Autism Spectrum Disorder?(Required) Diagnosed by Medical Doctor?(Required) Blood Discorder?(Required) Sickle Cell Anemia?(Required) Cancer? Explain:(Required)
Cardiac Heart Condition? Explain:(Required)
Cystic Fibrosis? If Yes, Name of medication if taking any:(Required)
Diabetes?(Required) Does student require insulin at school?(Required) Does student have Hypoglycemia?(Required) Does student have a Mental Health Condition?(Required) Does student have any other Medical condition not listed above? Explain:(Required)
Mark N/A if not applicable
Other medication(s) taken not listed above:(Required)
Mark N/A if not applicable
This student doesn't have any conditions or illnesses(Required) Does your student have insurance coverage? If yes, what insurance(s) names? (Private, Medicare, etc.)(Required)
(5) Student Five (5) is for the Fifth student when filling this application for more than one student.
(5) Fifth Student's Name(Required)
First
Middle
Last
Allergy To Ants(Required) Allergy To Wasps(Required) Allergy To Bee Stings(Required) Specify Reaction To Allergy or Allergen(Required) Does Student Have Asthma? If Yes, Age of diagnosis, Is student currently under Doctor's care?, What are triggers?(Required)
Does Student Have Attention Deficit/Hyperactivity Disorder (ADD/ADHD)? If Yes, Do they take medication? If so, what medication(s)?(Required)
Does student have Autism Spectrum Disorder?(Required) Diagnosed by Medical Doctor?(Required) Blood Disorder?(Required) Sickle Cell Anemia?(Required) Cancer? Explain:(Required)
Cardiac Heart Condition? Explain:(Required)
Cystic Fibrosis? If Yes, Name of medication if taking any:(Required)
Diabetes?(Required) Does student require insulin at school?(Required) Does student have Hypoglycemia?(Required) Does student have a Mental Health Condition?(Required) Does student have any other Medical condition not listed above? Explain:(Required)
Other medication(s) taken not listed above:(Required)
This student doesn't have any conditions or illnesses(Required) Does your student have insurance coverage? If yes, what insurance(s) names? (Private, Medicare, etc.)(Required)
I certify that the information I have provided on this Enrollment Application is accurate and true. I understand the school keeps all personal and medical information and records in accordance with the law.
Signature of Parent/Guardian(Required) Parent/Guardian's Name(Required)
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