Free Student Health Information Form Template
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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