Student Health Information Form 2021-22

Student Information

This form is only needed for enrollments for school year 2021-22.

Your Name *

Your Email Address *

You will receive a copy of your completed form at this email address.

Student's Legal Name (first middle last) *

Student Also Known As (nickname, etc.)

Student's Date of Birth * +

School *

Grade Entering *

Health Concerns

If your child has a serious medical condition, it is your responsibility to discuss this with your school nurse immediately. The school must know of LIFE THREATENING conditions (for example asthma, diabetes, nut/insect allergies with anaphylaxis, etc.) prior to starting school.

If an Individualized Health Plan is indicated, parent/guardian is responsible for contacting the School Nurse, as well as providing the school with necessary medical information, appropriate authorization forms, and written consent to exchange information with the child’s physician.

Please contact the appropriate nurse. This information will be included in your confirmation email as well.

Elementary school nurse at 405.707.5083 or -nurse-elementary@stillwaterschools.com

Secondary school nurse at 405.707.5177 or -nurse-secondary@stillwaterschools.com

Student has health concerns? *

Yes

No

Individualized Health Care/Emergency Plan Needed? *

Yes

No

Does student already have a health or emergency plan at Stillwater Public Schools? If answer is yes, and the plan needs to be updated, please contact the school nurse as soon as possible. *

Yes

No

List your child's allergies that may cause a problem at school.

Cause of allergies:

Treatment of allergies:

A life-threatening allergy to food, latex or stinging insects requires an Emergency Allergy Action Plan be developed and medication orders for an Epi-Pen to be in place before entry to school. Please contact the school nurse as soon as possible.

Medical History. Check any conditions that apply to your child and describe in the comment section.

Comments or how to manage health concern(s) at school: