Student Health Data

Student Health Data

Please complete the information below so that we have the most accurate health information possible for your student. If you need more space than what is provided below, please attach additional sheets. This will also serve as a release for the New York Education Department for the current school year.
Student Information
Student's name*

First NameLast Name
Student's date of birth*

MonthDayYear
Does the student have any ongoing health concerns? (Asthma, Diabetes, etc.)*

YesNo
Please describe the student's ongoing health concerns.
Does the student have any allergies?*

YesNo
Please list the allergies.
Has the allergy required emergency treatment?

YesNo
Please list the emergency treatments.
Does the student have any history of hospitalizations, significant injuries, or surgery?*

YesNo
Please describe the hospitalizations, injuries or surgery.
Does your child take any medication regularly at home?*

YesNo

Records Release
I give permission to the Geneva City School District to obtain and release any information to my student's doctor or dentist, including immunizations, physical exams, and progress notes. (Please note that protected information such as HIV status or mental health treatments requires a separate release.) I also give permission for the school nurse to share any pertinent medical information with my student's teacher(s) on a need-to-know basis.*

Check the box to indicate agreement.
Parent/Guardian's signature*

Clear
Parent/Guardian's name*

First NameLast Name
Today's date*

MonthDayYear
Should be Empty:

Student Information