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Health and 504/Special Education Form 2019-20
Please fill this out if your student has even received special education services and if they have a health issue so we can add it to your student's profile.
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Email
*
Your email
Your First and Last Name
*
Your answer
Your Student's First and Last Name?
*
Your answer
Has your student even been on an IEP or 504 (also known as special education or resource)
*
Yes
No
Yes but not in the last year
Please mark any health issues your student has that we should know about.
*
None
Asthma
Life threatening allergy (List allergy under other)
Diabetes
Chronic condition (List condition under other)
Allergy to medications (List allergy under other)
Seizures
Mental Health Related Issues
Other:
Required
Medication taken at home or school for emergency reference.
Your answer
Do you currently have health insurance or medical coverage? If not, you may call 1-877-543-7669 for information about CHIP (Children's Health Insurance Program) or Medicaid.
*
Yes
No
Do you give permission for us to share this health information with school personnel who have a need to know your child's health concerns such as their teacher and office staff?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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