Pierz Schools 2021-22 Confidential Health Form

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Please fill out one form for EACH child you have attending Pierz Public Schools (PK-12). A link to submit another form will pop-up after you submit each form.

Please complete this form as thoroughly and as soon as possible. Information collected helps us to provide the best possible medical care to your child during the school day. All information is confidential, and shared only with those who work directly with your child.

Email *

Student First Name *

Student Last Name *

Student Date of Birth *

YYYY

Grade *

Doctor/Clinic: *

Has your child received a COVID-19 vaccine? *

Yes

N/A under age 12

Has this child ever tested positive for COVID-19? *

Yes

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