Searcy Public Schools Health History Form
2020-2021 School Year
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Student's First Name *
Student's Middle Name
Student's Last Name *
Student's Birthdate (mm-dd-yyyy) *
What school is the student attending for the 2020-2021 school year? Please select one. *
Please select the student's grade. *
Parent Name(s) *
Street Address (Include House # or Apartment #) City, State, Zip Code *
Home Phone *
Cell Phone *
Work Phone
Doctor (List name and phone number) *
Dentist (List name and phone number)
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