The front of this form must be completed in it's ENTIRETY. If you have siblings, I can make a copy for each folder so only one copy is needed. Please review the back of the form. It does NOT need a doctor's signature unless you'd like to do so; otherwise it is redundant of the health inventory.

This form MUST be completed for EACH student. Parents/guardians should complete page 2 and the pediatrician's office will complete page 3 AND the Lead Testing Certificate. A completed printout of current immunizations is REQUIRED.

This form MUST be completed by the doctor's office and submitted to the preschool IF your child requires an epi-pen, inhaler, etc. The medication MUST be in it's original packaging from the pharmacy with the completed form.

Please complete the top half OR the bottom half and submit it to the office. Families can change this form as needed by printing a new one and submitting it.