JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Health Form 2021/2022
Focus Preparatory
Sign in to Google
to save your progress.
Learn more
Student Name
Your answer
Student Age
Your answer
Student Birthdate
MM
/
DD
/
YYYY
Mailing Address
Your answer
Parent/Guardian Name(s)
Your answer
Parent/Guardian Phone Numbers
Your answer
Parent/Guardian Email addresses
Your answer
Emergency contact other than parent/phone number
Your answer
Health Insurance Provider
Your answer
Policy Number
Your answer
Family Doctor and phone number
Your answer
Preferred hospital in case of emergency
Your answer
Food allergies
Your answer
Drug or environmental allergies or other health concerns
Your answer
Persons who may pick student up.
Your answer
If my child is complaining of pain or itchiness, gets a minor cut, or has an allergic reaction, this serves as written permission for my child to be given an age-weight appropriate dose by the school health officer:
band aid
Anti-bacterial Cream
Ibuprofen or acetaminophen
benadryl
antacid
sunscreen
insect repellant
Other:
I give permission for a paramedic to treat my child, and for my child to be transported by ambulance if an emergency situation occurs—even if a parent cannot be reached.
Choose
Yes
No
I understand that students with any covid-19 symptoms should be kept home from school.
Yes
No
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
