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School Nurse Information
* Indicates required question
Email
*
Record my email address with my response
Student Name
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
What School does your student attend?
*
KID Elementary
Hubbard Elementary
Pioneer Elementary
Middle School
High School
Does your student have any documented allergies to foods?
*
No
Yes
If Yes, please list food allergies.
Please note that a copy of the doctor's note is required. This can be given to the school's front desk.
Your answer
Will your student have an EpiPen at School?
*
No
Yes
Allergy to Latex?
*
No
Yes
Allergy to any Insects?
*
No
Yes
If Yes, please list Insects.
Your answer
Does your student have a seizure disorder?
If Yes, a copy of the doctor's
seizure plan
is required. This can be given to the school's front desk or nurse.
*
No
Yes
Does your student have Diabetes?
If Yes, a copy of the doctor's
diabetes
plan
is required. This can be given to the school's front desk or nurse.
*
No
Yes, Type 1
Yes, Type 2
Other:
Will your student have Insulin at school?
*
No
Yes, CGM
Yes, Pump
Yes, Other
Does your student have any mental health disorder we should know about? Please check all that apply.
ADHD
Anxiety
Autism
Bipolar
Depression
OCD
PTSD
Schizophrenia
Other:
Does your student have any of the following? Please check all that apply.
Alpha Gal Syndrome
Arthritis
Bleeding Disorders
Cerebral Palsy
Down Syndrome
Heart Murmur
Irritable Bowel Syndrome
Tourette’s Syndrome
Vision Problems
Other:
Please add any other information that would be helpful for the school nurse.
Your answer
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