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Student First Name:*

Student Last Name:*

DOB:*

Date of Last Physical:

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

Failure to file either proof of immunizations or medical/religious exemptions 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 (use mouse)

Date:*

Gender:

Grade:*

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

New Student Returning Student

Before submitting this form, please check your answers. Any questions with a red * are required. After submitting the form if you get a validation error, please look for and complete any questions/fields that turn red.

Jordan-Elbridge Central School District

Health Registration Form

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Draft name: