Request for District Pupil Health Services

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The State of Minnesota has authorized local public school districts to allow pupils attending a nonpublic school (includes home schools), established and operating within the school district boundaries, access to the existing district Pupil Health Services program. These services must be requested by, or on behalf of, the pupil NO LATER THAN SEPTEMBER 15th of the current school year.

Email *

School year ending *

YYYY

Pupil's Name *

Grade level (kindergarten is 0) *

Name of School *

Please indicate whether or not you request these items this school year. *

I do request that the district's Pupil Health Services program be made availiable to the above pupil this school year.

I do NOT wish to request Pupil Health Services this school year.

I understand that by typing my name below, I am signing this form electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this form. *

Today's Date *

YYYY

Send me a copy of my responses.

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