Wilshire Park Elementary Annual Health Update 2022-2023
This is an annual form that we request families to fill out every year.  Health Office staff will review this information and may contact you with any additional questions.  This information is shared private in your student's file and used for medical purposes and emergencies only.  

If you have more than one child in our district, please fill this form out for each child attending one of our schools. Note that each school has a different survey.  Thank you!
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Student's First Name *
Student's Last Name *
Student's Grade in 2022-2023 *
Required
Emergency #1 Contact Name & Relationship  *
Emergency #1 Phone Number *
Emergency #2 Contact Name & Relationship *
Emergency #2 Phone Number *
Emergency #3 Contact Name & Relationship
Emergency #3 Phone Number
In case of an emergency, what hospital would you like us to transport your child to? *
Does your child have any allergies?  These may be allergies such as seasonal, food or environmental?  Does your child have a prescription EpiPen? *
Does your child take any medications?  If yes, please list the name and dose of the medication and the reason for the medication.  If no, write No.   *
Has your child had any injuries or illnesses in the last 12 months?  If yes, please list.  If no, write No. *
Does your child have any chronic conditions?  If yes, please list.  If no, write No.  

Chronic disease and conditions are broadly defined as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.
 *
Does your child have health insurance?  
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Do you have any comments or information to share with Health Office staff?  
By typing your name below, you are stating the information you have shared in this form for your child is current and up to date for the 2022-2023 school year.  If anything changes or there are health related issues with your child during the school year, you will contact your child's building attendance or nurse offices. *
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