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EP Summer Health Update
2020-2021
Parents/Guardians:
Please complete the following information and submit electronically, as soon as possible, so we can update our health records to ensure your child's needs are met at school.
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Email
*
Your email
Email address
*
Your answer
Name of the Parent/Guardian Completing this Form:
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Your answer
Student's Last Name
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Your answer
Student's First Name
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Your answer
Grade
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Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
During the past year, has your child had a serious injury?
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Yes
No
If Yes, please explain
Your answer
During the past year, has your child had a serious illness?
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Yes
No
If Yes, please explain
Your answer
During the past year, has your child had any surgeries?
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Yes
No
If yes, please explain
Your answer
During the past year, has your child had an allergic reaction?
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Yes
No
If Yes, please explain
Your answer
Please list current medications
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Your answer
Does your child have any activity restrictions (physical education, sports, recess)? Please note that, if there are any restrictions, you must supply us with a note from a medical doctor stating the reason and duration of the restriction.
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Yes
No
If yes, please explain
Your answer
Electronic Signature Parent/Legal Guardian
*
Your answer
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