Health Information Form 2026-2027

Student’s Name (first and last name)

School Name

Grade

Student ID

Health Diagnoses

Date of Most Recent Seizure

Other Allergies, conditions, disabilities or illness we should be aware of in the Health Room? If yes, please specify.

Condition Details or Notes

No known allergies

Food and Drug Allergies

Emergency Medication perscribed?

Behavioral, Mental, and Emotional Concerns - Diagnosis (if none, please type N/A)

Will your child be taking a daily medication at school?

If your student needs to take medication at school, the parent/guardian will need to bring the medication in the original container to the school nurse, and complete the reqired forms.

Does your child take medication "as needed" that may need to be given at school. Please note that the medication AND a doctor's order must be provided to the Nurse in order for the medication to be given. "As needed" refers to prescription medication as well as over the counter medication such as ibuprofen, acetaminophen, etc.

Required Health Procedures or Special Services (if none, please type N/A)

Does your child have the following

If new to LRSD please upload records here.

ARKids/Medicaid ID Number

No Health Insurance

Insurance/Health Care Providers Information

The Health Services Department of the Little Rock School District provides Vision and Hearing Screenings to students in grades PK, K, 1st , 2nd , 4th , 6th, and 8th grades and any other students as requested. This services is free to families. If you sign below your Health Insurance will be billed. You will NOT get a bill. You will NOT have a copay. Please SIGN YOUR NAME BELOW to consent to release education records related to vision and hearing screenings. The agency that helps us only sees the date of the screening, not the results. In compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 123g; 34 CFR Pan 99)

Signature

Please SIGN BELOW - I give consent for emergency medical treatment. I understand that I will be responsible for payment of any and all medical care services, including but not limited to emergency care that is not covered by the student’s health insurance. I give consent for this information to be shared with my child’s teacher and appropriate school staff. I certify all information given is correct.

Parent Signature

Health Information Form

Student and Contact Information

Medical Diagnoses and History

Allergies and Emergency Medication Permission

Behavioral, Mental, and Emotional Concerns

Medications and Special Health Procedures

Hearing/Vision

Vaccination Record

Insurance and Coverage

Consent and Signature