Student Information

 

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Student Demographics

The following questions are required per the State of Iowa Department of Education for use in reporting.

Asian
African American or Black
Native American / Alaska Native
Native Hawaiian / Other Pacific Islander
White

 

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Family Information

Legal Guardian 1

 

Legal Guardian 2

 

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School Health Information

Is your child allergic to medication, food, bee stings, or environmental allergens?

Yes No

Does your child take medication(s) on a routine basis?

Yes No

Does your child have a medical diagnosis of a chronic health condition such as diabetes, asthma, heart problems, seizures, etc.?

Yes No

Do you give permission to treat a cut with triple-antibiotic ointment?

Yes No

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Non-Guardian Emergency Contacts


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Additional Student Pickup Contacts

Would you like to add any additional Contacts that are authorized to pick up your student?

Yes No

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