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Woodsville Elementary School Health Information
New Student (1st-3rd)
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* Indicates required question
First & Last Name of Child:
*
Your answer
Please list any serious illness, allergy or disability
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Your answer
Emergency Procedures:
Your answer
Does your child take daily medications?
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Yes
No
Medication permission form on file with the school nurse?
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Yes
No
Does not take any medications
If your child takes any medications, please list below current list of medications:
Your answer
Please Note: All medications must be in original container, with the written doctor's note and brought into school by an adult. All inhalers must be kept in the nurse's office at all times.
Please list any immunizations your child had over the summer (if none, please state that)
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Your answer
Does your child have health insurance?
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Yes
No
If your child does have health insurance, please list the provider:
Your answer
Your child's doctor is:
*
Your answer
Phone number of your child's doctor:
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Your answer
Your child's dentist is:
*
Your answer
Phone number of your child's dentist
*
Your answer
Date of completion of this form:
*
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This form was created inside of School Administrative Unit # 23.
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