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Health Records for Kindergarten Students 2022-23
This must be completed before your child attends kindergarten. It is filed with the school nurse for reference.
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* Indicates required question
Student's Legal Name: (First, Middle, Last)
*
Your answer
Option 1
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My child is:
*
Boy
Girl
Date of Birth
*
MM
/
DD
/
YYYY
Parent/Legal Guardian Name:
*
Your answer
Street Address, City, State, Zip
*
Your answer
Contact Number (Ex. 999-999-9999)
*
Your answer
Name of Doctor
Your answer
Date of last physical
MM
/
DD
/
YYYY
Name of Dentist
Your answer
Date of last dental exam
MM
/
DD
/
YYYY
Name of Eye Doctor
Your answer
Date of last eye exam
MM
/
DD
/
YYYY
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