Bentworth School District

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Welcome to the Bentworth School District!!                  Title 1 Distinguished Elementary School               Ranked as a U.S. News Best Middle School              Identified as a Schools To Watch Middle School  (3x)            National Blue Ribbon High School                       Ranked as a U.S. News Best High School                Bentworth High School Global Educational Excellence Award            

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HEALTH RECORD FOR REGISTRATION

Bentworth School District

Health Record for Registration

Gender*
Answer Required

CHILD'S MEDICAL HISTORY

Please check yes/no for each question

If YES, please provide an explanation 

Please include any medications that apply.

Allergies to food, drugs or environment:*
Answer Required
Cardiac Issues*
Answer Required
Urinary or Bowel issues:*
Answer Required
Seizures*
Answer Required
Diabetes*
Answer Required
Have they had Chicken Pox? *
Answer Required
Ear Infections:*
Answer Required
Asthma:*
Answer Required
Vision Issues / glasses:*
Answer Required
Tonsillitis / Tonsillectomy:*
Answer Required
Stomach Issues:*
Answer Required
Hearing issues / Hearing Device:*
Answer Required

Immunizations:  A copy of your child's immunization record must be submitted / attached with this document.

Doses required by law for school students

K - 1st Grade: Diphtheria and Tetanus (4) the 4th being on or after the 4th birthday, Polio (4) the 4th being on or after the 4th birthday and 6 months after the last dose given, Hepatitis B (3), Measles / Mumps-Rubella (MMR) (2) and Varicella (Vaccine (2) or Disease).

7th Grade: 1 dose of Tetanus, Diphtheris, Acellular Pertussis (Tdap), Meningococcal Conjugate Vaccine (MCV) before the first day of 7th grade.

12th Grade: 1 dose of Meningococcal Conjugate Vaccine (MCV) before the first day of 12th grade.  If one dose was given at 16 years or older, that shall count as the 12th grade dose.

Please schedule your child for the immunizations they have not received and provide written verification to the school nurse before the beginning of school.