Dear Parent/Guardian: The American Academy of Pediatrics recommends children receive a physical examination annually. Health information is vital in planning and supporting students while attending school. Please provide us with current health information. State Law (M.S. 123.70 & M.S. 144.29) requires your child be immunized & receive a comprehensive physical examination before entering Kindergarten or elementary school.

* Please Note: WRITTEN CONSENT IS REQUIRED BY BOTH THE STUDENT’S GUARDIAN AS WELL AS THEIR HEALTH CARE PROVIDER. Complete a Medication Administration Form for ANY medication (BOTH PRESCRIPTION AND NON-PRESCRIPTION) needing to be administered during school hours (forms are available in the Health Office).

I attest to the information provided. I acknowledge that it is my responsibility to inform the school of any changes to the health status of this student including health conditions, needs, medications, and/or allergies. I understand and agree that this student may receive a routine screening for any vision and hearing deficiencies. I will comply with all school illness and medication policies. Furthermore, I give permission for school health staff to confidentially exchange health information - both within the school as well as with outside health care providers - for use in meeting this student’s health and educational needs in school.