Portal

Forms Portal

This form no longer exists. You will not be able to submit this form.

Your form is outdated. Click here to update your form to the most current version.

Student First Name:*

Student Last Name:*

DOB:*

Liverpool Central School District Health Registration Form

New Student

Returning Student

Date of Last Physical:

Proof of NYS required immunizations must be presented at the time of registration.

If there is a medical exemption, statements of such must be presented.

Failure to file either proof of immunizations or medical exemption may result in the exclusion of the pupil until such statements are submitted.

Student's Medical Doctor:

Phone Number:

Current Medications:

Yes No

Chicken Pox:*

Yes No

Ear Infections:*

Yes No

Asthma:*

Type

Medication:

Yes No

Food Allergies:*

Yes No

Allergies (other than food):*

Yes No

Heart Condition:*

Onset:

Medication:

Yes No

Glasses or Contacts:*

Yes No

Hearing Impairment:*

Yes No

Speech Concerns:*

Yes No

Operations:*

Yes No

Serious Injuries:*

Yes No

Hospitalizations:*

Yes No

Diabetes:*

I II

Type:

Onset:

Yes No

Seizure Disorder Type:*

Onset:

Medication:

Medical Provider:

Other Concerns (List below):

Parent/Guardian Signature

Date:

Gender:

Grade

You answered Yes to a Health Question Above - please contact Building Nurse

Save Draft

Draft name: