Check any of the following that apply to your student
Please give date and details for any illness or injury checked above
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Major Illnesses (Please be specific)
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Significant Injuries (Please be specific)
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Daily Medication
If your child is presently taking medication for an extended time and will be taking it during school hours, please list below:
Name of Medication(s) and time and schedule of administration
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Optional: Medications your child takes during non-school hours
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Please type your full name (parent or legal guardian) below, even in the event that none of this applies to your child, to acknowledge you have read and completed this form. *
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