2023-24 Lipscomb Academy Health Form 
Completion of the Health Form will allow Clinic Nurses at Lipscomb 
Academy School to provide certain medications throughout the 2023-24 school year. 
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Email *
Name of Parent/Guardian completing this Health Information Form *
Student's Last Name *
Student's First Name (preferred) *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's L Number (including the L - ex. L20612121) *
Grade
Mark only one box
 *
Required
List any allergies or conditions in regard to this student of which we should be aware, such as, nut allergies, emotional conditions (such as, anxiety, depression, etc.), or any medical condition (such as diabetes, asthma, etc.)  If there are none, please write N/A.  Please note that if your student needs any minor adjustments to participate in a program at Lipscomb Academy, you must separately contact the Academic Support Program. *
By signing this form, I hereby give the school nurse or designated school employee permission to give my the over-the-counter medicines indicated below. 
Dosage is based on package instructions, and may be a generic brand.


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