Form from: Holy Family Academy

2025 - 2026 Annual Student Health Form (K - 8th Grade)

Student Name

Student Birth Date

Student Gender

Student Grade (Fall of 2025)

Health or Disability Concerns

Please indicate if your child has any of the below health concerns.

Allergic Reactions

Please describe reaction:

Asthma or other breathing problems

Please describe condition and any treatment:

Attention Disorder

Please describe condition and any treatment:

Diabetes

Diabetes Type and Treatment

Comments:

Heart Problem

Please describe condition and any treatment:

Hearing Loss

Please indicate hearing loss and treatment:

Vision Impairment

Does your child wear glasses or contacts?

Seizures

Please describe condition and any treatment:

Recent Surgery or Hospitalization

Please describe:

Social, Emotional or Behavioral Concerns

Please describe:

Any other health concerns or additional health information:

Emergencies

Does your child have a health concern or condition that could result in an emergency?

If yes, please describe in detail:

Medications

Does your child take any medications, either daily or on an as needed basis?

Please list ALL medications your child takes daily or as needed. Include name of medication, purpose, dose and how often it is taken.

NOTE: Consent forms are required for ALL medications at school and are available from the health office.

Parent and Clinic Information

Parent Name

Parent Daytime Phone Number

Primary Doctor or Clinic Name

Clinic Phone Number

Acknowledgement

I acknowledge that the information provided above is true and accurate to my knowledge.

Digital Signature

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Health Services Information

Please read through the following information regarding health services.

1. MEDICATIONS: All prescription medication given at school must be in a labeled original bottle from the pharmacy. Any prescription medication requires written authorization from your doctor as well as written permission from the parent to give the medication. *Medications will not be given if there is not a physician order at school*. If a medication dosage changes or the medication is restarted, we will need a new written order from your doctor and a new parental permission form signed. We will not give any medication unless these instructions are all in order.

o Asthma: Please make sure your student has an inhaler available for use at all times (even if the student has not needed an inhaler for a year). If you want your child to carry an inhaler on their person (as opposed to keeping in the health office) we still need to have both the doctor and parent written authorizations. We also need to know WHERE the student keeps his/her inhaler (backpack, locker, pocket etc.) in case they need it quickly.

o Diabetes: If your child is diabetic, we need to know what type of insulin regime he/she is on, written physician orders for insulin and parent authorization. A short meeting with the school nurse is required to set up a health management plan for the year. This will give your child the most independence along with the highest level of safety.

o Epi- Pen: If your student needs an Epi- Pen for allergic reactions, PLEASE sent it to school on the first day. Also, check the medication has not expired. Your child will also need an emergency health plan filled out and written doctor and parent authorization for an Epi-pen.

If your child will need over the counter medication at school, it must be provided in the original container. No pills brought to school in plastic bags or unlabeled will be accepted. Parent should send written instructions with the name of medication, dosage, when to be given, reason to be given and a parent signature. We do not keep any over the counter medications at school not provided by a parent for a specific child. **No homeopathic, natural or vitamin supplements are allowed at school, these should be given at home only.

2. IMMUNIZATIONS: It is your responsibility to provide immunization records to health services or fax to school. ALL STUDENTS must turn in proof of immunizations and be in compliance with MN School Immunization Law (MS 121A.15). This law states each student must have current immunization records on file at the school (Kindergarteners & 7th graders have additional requirements). If your student has had shots recently please provide documentation to the health office.

3. EMERGENCY PLAN:  If your student has a health condition that would necessitate an emergency health plan (asthma, allergy, other health concern) or if the student had an emergency health plan for the previous year, you will need to fill out or update this form with the district nurse.


I have read and acknowledge the above Health Services Information.

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