Health Form

2020-2021 GLR Student Health Registration

  • MM slash DD slash YYYY
  • When child is ill or injured, please list which parent/guardian the school should notify first. Please list in preferred order of contact.
  • In case parent can’t be reached, please contact the individual below: This person has agreed to assume this responsibility and is local.

    Mark the box if your child has a history of the following conditions. Mark additional information as needed. Additional forms may need to be completed by your physician (marked with *). Forms available on school website.
    Doctor’s note required for explanation*
    List medication towards the end of the form
  • Medications

    List ALL medications taken regularly at home or at school. Please specify frequency and reason for use.