HEALTH RECORD FOR REGISTRATION

Bentworth School District

Health Record for Registration

Date:*

Answer required for "Date:"

Student's Legal First Name*

Answer required for "Student's Legal First Name"

Student's Legal Middle Name

Answer required for "Student's Legal Middle Name"

Student's Legal Last Name*

Answer required for "Student's Legal Last Name"

Date of Birth*

Answer required for "Date of Birth"

Last school attended:*

Answer required for "Last school attended:"

Name of last school district attended? *

Answer required for "Name of last school district attended? "

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 for "Allergies to food, drugs or environment:"

YES

Explanation and/or medications:

Answer required for "Explanation and/or medications:"

Cardiac Issues*

Answer required for "Cardiac Issues"

YES

Please describe any cardiac issues:

Answer required for "Please describe any cardiac issues:"

Urinary or Bowel issues:*

Answer required for "Urinary or Bowel issues:"

YES

Please describe the type of issues:

Answer required for "Please describe the type of issues:"

Seizures*

Answer required for "Seizures"

YES

Type of seizures? Medication?

Answer required for "Type of seizures? Medication?"

Diabetes*

Answer required for "Diabetes"

YES

Type of treatment?

Answer required for "Type of treatment?"

Have they had Chicken Pox? *

Answer required for "Have they had Chicken Pox? "

YES

If they have had Chicken Pox, please list the date of illness.

Answer required for "If they have had Chicken Pox, please list the date of illness."

Ear Infections:*

Answer required for "Ear Infections:"

YES

Frequency of ear infections:

Answer required for "Frequency of ear infections:"

Asthma:*

Answer required for "Asthma:"

YES

Medications:

Answer required for "Medications:"

Vision Issues / glasses:*

Answer required for "Vision Issues / glasses:"

YES

Please describe the vision issues:

Answer required for "Please describe the vision issues:"

Tonsillitis / Tonsillectomy:*

Answer required for "Tonsillitis / Tonsillectomy:"

YES

Stomach Issues:*

Answer required for "Stomach Issues:"

YES

Please describe the stomach issues:

Answer required for "Please describe the stomach issues:"

Hearing issues / Hearing Device:*

Answer required for "Hearing issues / Hearing Device:"

YES

Please describe the hearing issues and hearing device:

Answer required for "Please describe the hearing issues and hearing device:"

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.

Please fix the highlighted areas below before submitting.

HEALTH RECORD FOR REGISTRATION