Student Health Information Form Template
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Student Health Information Form
Please fill out this form completely to provide important health information for your child.
Student Information
Name
Date of Birth
Grade
School
Parent/Guardian Information
Name
Phone number
Medical History
Please list any medical conditions or allergies
Emergency Contact Information
Name
Relationship to Student
Phone number
Insurance Information
Insurance Provider
Policy Number
Authorization
I give permission for the school to share this health information with relevant personnel as necessary.
Name:
Date:
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