Health Services Forms - OLR
REQUIRED to be updated each school year - Please print out the forms that are applicable to you and submit them to the office prior to the start of the school year.  Any questions regarding health updates can be directed to School Nurse, Kristina Gabrielse at kgabrielse@cgbrockets.com or ext.233, thank you.
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Email *
Student's FIRST Name *
Student's LAST Name *
Student's Grade Level *
Current Health Information
REQUIRED for ALL ELEMENTARY STUDENTS.  Click the link to print and complete your student's current health information.  https://www.cgbrockets.com/docs/building/3/current%20health%20information%20es%202019-2020.pdf?id=4186  Please check the box to indicate if you will be turning a form into the office.
Immunization Record
Required for Kindergarten students, Grade 6 students, new enrollments and updates.  https://dhs.wisconsin.gov/forms/f0/f04020l.pdf  Please check the box to indicate if you will be turning a form into the office.
Food Allergy and Anaphylaxis Action Plan
https://www.cgbrockets.com/docs/district/depts/2/emergency-care-plan.pdf?id=1212  Please check the box to indicate if you will be turning a form into the office.
Asthma Action Plan
https://www.cgbrockets.com/docs/district/depts/2/asthma-action-plan.pdf?id=1208  Please check the box to indicate if you will be turning a form into the office.
Asthma Inhaler Administration Authorization
https://www.cgbrockets.com/docs/district/depts/2/asthma-inhaler-authorization.pdf?id=1209  Please check the box to indicate if you will be turning a form into the office.
Individual Health Action Plan
https://www.cgbrockets.com/docs/district/depts/2/individual-health-action-plan.pdf?id=1213  Please check the box to indicate if you will be turning a form into the office.
Medication Administration, Over-the-Counter
This form is required if your child will be taking medication at school.                                                     https://www.cgbrockets.com/docs/district/depts/2/medication-over-the-counter.pdf?id=1210  Please check the box to indicate if you will be turning a form into the office.
Medication Administration, Prescription
This form is required to be on file if your child will be taking prescription medication at school.  Doctor authorization is required on the form.  https://www.cgbrockets.com/docs/district/depts/2/medication-authorization-prescription.pdf?id=1211  Please check the box to indicate if you will be turning a form into the office.
Seizure Action Plan
https://www.cgbrockets.com/docs/district/depts/2/seizure-action-plan.pdf?id=1207  Please check the box to indicate if you will be turning a form into the office.
Name of Person Completing Information *
Printed/Completed Health Services Forms *
Please print forms that are applicable to you, and check one box to notify the office.  Click Submit.  Thank you!
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