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Searcy Public Schools Health History Form
2020-2021 School Year
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* Indicates required question
Student's First Name
*
Your answer
Student's Middle Name
Your answer
Student's Last Name
*
Your answer
Student's Birthdate (mm-dd-yyyy)
*
Your answer
What school is the student attending for the 2020-2021 school year? Please select one.
*
Choose
McRae Elementary School
Sidney Deener Elementary School
Westside Elementary School
Southwest Middle School
Ahlf Junior High School
Searcy High School
Please select the student's grade.
*
Choose
Kiindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Parent Name(s)
*
Your answer
Street Address (Include House # or Apartment #) City, State, Zip Code
*
Your answer
Home Phone
*
Your answer
Cell Phone
*
Your answer
Work Phone
Your answer
Doctor (List name and phone number)
*
Your answer
Dentist (List name and phone number)
Your answer
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