School Physical Survey

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PA School Health Regulations require students to have a comprehensive Physical Evaluation by a licensed provider during Kindergarten and Grade 6. You may have this examination completed by your family's medical provider at your own expense, or the examination may be completed at the school by our school physician at no cost to you. There are no set dates at this time, but the proposed dates will be at the end of March or the beginning of April. Please indicate below if you will be participating in the school sponsored physicals.

Student's Name *

Student's ID Number *

Student's Grade *

Kindergarten

6th Grade

Please indicate your preference below for Choice A or B. *

Choice A - My child will have a physical examination completed by our family's medical provider. I will provide a copy of this physical to the school nurse as soon as it is completed.

Choice B - I request that my child have a physical examination completed by the school physician at no cost to me.

If you have selected Choice B, please indicate if you plan to be present during the Physical Exam.

I will attend the physical examination.

I will not be able to attend the physical examination.

Clear selection

Name of person completing the survey: *

Relationship to student: *

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