Editing previous response:

Please fix the highlighted areas below before submitting.

Health Room Form

Student Information

Answer Required

Home Address

Answer Required

Chronic Health Conditions

Select all that apply*
Answer Required


Medication 2

Medication 3

Medication 4

**Medication policy: A Health Care Provider (MD,DO ARNP,PA,Dentist or Orthodontist) order must be on file at your student's school for any prescription or over the counter medication to be given at school or school events. Information regarding Self Administration of Asthma inhalers and/or Epinephrine pens is available in the student handbook/agenda and on the USO 509 medication form. A new Health Care Provider order and parent/guardian authorization is required every school year. Please contact the school nurse-with questions or concerns.

**Health records are confidential: The School Nurse will share this information with the staff members when it specifically relates the students learning or safety at school, or school sponsored events. USO 509 Nurse participates and inputs immunization information into the Kansas Immunization Registry(Weblz), Immunization information disclosed in Weblz will be used for purposes of assessment and reporting to prevent disease. USO 509 Nurse may also consult with the Student's Health Care Provider as listed above regarding immunizations and/or health needs. USO 509 Nurse may also consult with Sumner County Health Dept. regarding immunizations. By signing below, I am giving consent for my student's records to be entered &/or updated in Weblz and the student information system.

**Screenings: Vision and Hearing screenings are offered to students per Kansas Statutes. Free Dental screening will also be done annually per statutes for the purpose of notifying parents of any possible dental issues & data collection. If you do not want your student to be screened, provide written request to the school declining specific screenings. Head lice screenings and other periodic health screenings may be offered or provided during the school year. 

**Consent for treatment of illness or injury at school: The school nurse or designated staff will care for ill or injured students. If the student cannot return to class, contact with the parent/guardian(P/G) or other emergency contact person will be initiated. P/G or emergency contact person(s) will be notified prior to a student being picked up or released from school. Please keep the school notified of any change of contact numbers. In the rare event a student needs immediate physician/hospital care and P/G cannot be reached, 911 will be call to transport the student to our local hospital for care. The school will continue to contact the P/G.

**By signing below I affirm that I am authorized to consent to the release of medical information on behalf of the student named above. I understand that this authorization will expire when the student is no longer enrolled in the above named School District &/or that I may revoke this authorization in writing at any time. I also consent to the school screenings as outlined above and illness/injury treatment.

Parent/Guardian Signature*
Signature Required

Sign this form

By pressing “Sign Form,” you are agreeing to signing this form electronically.
Signature *
Type to sign
Draw your signature

Confirmation Email