COLLINS MS - Student Health Form (2020-21)

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Please complete the below form within the first week of school to ensure that the school has accurate and up-to-date student health information for your child. Please complete ONE FORM PER STUDENT who is enrolled in the COLLINS MIDDLE SCHOOL. If you have a child enrolled in another school, please complete the form for that school. Please contact your school with any questions.

PROTECTING YOUR PRIVATE INFORMATION: Please know that all of the information you share within this form will be kept confidential. The information will go directly to and be managed by the school nurse who will when and if any other staff members (such as the school principal) need to be informed. The settings of this electronic form have also been bolstered with privacy and security settings to reinforce privacy protections.

Should you have any concerns about submitting the information electronically, please contact your School Nurse (Jane Morrissey at jmorrissey@salemk12.org) or your school office at 978-740-1193 to discuss alternatives such as completing a printed form and submitting your responses by mail.

Thank you.

Email *

Your Name (Parent/Guardian Name) *

Student First Name *

Student Last Name *

Student Date of Birth *

YYYY

Student's Gender *

Male

Female

Non-Binary

Student Grade Level in 2020-21 *

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