Student Health Form

Student Information

Student's Legal Name *

Student Last Name *

Birthdate * +

Grade *

New to NOVA? *

T-Shirt Size *

Indicate if your child will be interested in music.

Strings

Band

Choir

Address *

City, State, Zip *

Language Spoken at Home

Student lives with: *

Parent/Legal Guardian's Information - where student resides

Parent 1/Legal Guardian's Name *

Primary Phone *

Text? *

Yes

No

Secondary Phone

Email Address *

Parent 2/Legal Guardian's Name

Primary Phone

Text?

Yes

No

Secondary Phone

Email Address

Contact Information for second household, if applicable (non-custodial parent)

Parent 1/Legal Guardian's Name

Primary Phone

Text?

Yes

No

Secondary Phone

Email Address

Address

City, State, Zip

Parent 2/Legal Guardian's Name

Primary Phone

Text?

Yes

No

Secondary Phone

Email Address

Emergency Release Information

In a medical emergency, we will do our best to contact parent/guardians above. If we are unable to reach you, please list your emergency contact:

Emergency Contact *

Primary Phone *

Student Health Information

This questionnaire is designed to aid NOVA staff in anticipating any health concerns that might affect your child's safety or learning.

Health Care Provider: *

Phone *

Medical Insurance *

None

DSHS/Medicaid

Military/TriCare

Private Private

Please check any that apply

Are there any concerns with your child's health that NOVA should be aware of? *

No	Yes - Explain Yes - Explain

Does your child have allergies?

No	Yes: describe Yes: describe

Does your child have asthma?

No

Yes

Asthma

with inhaler

without inhaler

with 'Permission to Carry"

Describe Describe

Does your child's health problem affect his/her daily living or school participation *

No	Yes - Explain Yes - Explain

Other Health Concerns

Potentially Life-Threatening Conditions

NOVA School adheres to state law RCW 28A.210.320 which requires every public school to prohibit the attendance at school for any and all purposes for any student with a “Life-Threatening Condition” who does not have medication or treatment orders and a nursing care plan on file at the school. A “Life-Threatening Condition” is defined as a health condition that will put the child in danger of death during the school day if medication or treatment orders and a nursing care plan are not in place. Students who are not in compliance with RCW 28A.210.320 are prohibited from attendance until such time that they come into complete compliance.

Does your child have a Life-Threatening Allergy? *

Yes

No

Allergic to:

Describe Reaction

Date of Last Reaction

Does your child have seizures? *

Yes

No

Type

Does your child have a Cardiac Condition? *

Yes

No

Describe

Does your child have Diabetes? *

Yes

No

Type

Does your child have severe Asthma? *

Yes

No

Describe

Has your child been hospitalized or treated in emergency within past year? *

Yes

No

Did your child have an Emergency Action Plan (EAP) at his/her previous school? *

Yes

No

Has your child's health care provider advised you to have an EAP at NOVA? *

Yes

No

Does your child have "permission to carry" EpiPen, inhaler, other? *

Yes

No

n/a

Medications

NOVA School’s POLICY, as guided by WA State law: Medications, either prescribed or over-the-counter, may be administered to students only with WRITTEN PERMISSION of the parent/guardian AND a licensed health care provider. Medications need to be brought to school by an adult, in the original container, properly labeled with directions as ordered by provider and student’s name.

Health Concerns at this time:

None

Medication Used 🛈

	Taken at:
School	Taken at:	Taken at:
Home	Taken at:	Taken at:

Medication Used 🛈

	Taken at:
School	Taken at:	Taken at:
Home	Taken at:	Taken at:

Medication Used 🛈

	Taken at:
School	Taken at:	Taken at:
Home	Taken at:	Taken at:

Medication Used 🛈

	Taken at:
School	Taken at:	Taken at:
Home	Taken at:	Taken at:

Other Medication Concerns or Information

I understand that the medical information provided above is confidential, but may be shared, when indicated, with those that need to know in order to provide a safe environment for my child. *

Yes

Per WA State law, NOVA School requires that students EITHER be fully up to date on immunizations OR, for any vaccinations not given, that a current “Certificate of Exemption” signed by the health care provider and parent be on file, in order to attend school. I understand this policy. *

Yes