Student Medical Information Online Form

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STUDENT FORMS

2024-25 STUDENT MEDICAL INFORMATION ONLINE FORM

* Indicates required field

Student's Name *

First

Last

Student's Gender *

Female Male

You do not need to provide information on medical concerns; however, the information could be crucial to your student's well-being.

Are there any serious conditions about your student that you (the parent or caregiver) think White Bear Education Complex should be informed.

If Other: *

Is your student's immunization up-to-date? *

Allergies:

Does your student have any known drug, food, or other allergies? *

If Yes, what is your student's allergy, and what is/are the reaction(s)?Comment *

What are the symptoms to watch for? *

What is the immediate treatment? *

Emergency Contact:

Emergency Contact #1 Name *

First

Last

Relationship to Student *

Contact #1 Phone Number *

Emergency Contact #2 Name *

First

Last

Relationship to Student *

Contact #2 Phone Number *

Submit