LHA CONFIDENTIAL STUDENT HEALTH INFORMATION

PLEASE COMPLETE AND RETURN PRIVATELY TO THE ADMINISTRATION DESK

CONFIDENTIAL: This information is collected to help LHA respond appropriately to your student's needs while on site.

Please return this form directly to the administration desk rather than to a tutor or classroom.

Student Name:

Grade:

Parent/Guardian(s):

Primary Phone:

Emergency Contact / Phone:

MEDICAL CONDITIONS / DIAGNOSES

Please list any medical diagnoses, chronic conditions, or health concerns LHA should know about:

None known / none to report

MEDICATIONS

List medications the student currently takes that may be relevant while at LHA (name, purpose, timing if applicable):

None Student may carry medication while on site Medication may be needed during program hours

ALLERGIES / SENSITIVITIES

No known allergies Food Medication Environmental Other

Allergy / sensitivity and reaction:

EMERGENCY / SUPPORT INFORMATION

What should LHA staff do or know if this student experiences a medical issue, allergic reaction, or other concern?

OTHER INFORMATION THAT MAY HELP US SUPPORT YOUR STUDENT:

I confirm that the information above is accurate to the best of my knowledge and understand that I should notify LHA if important health information changes.

Parent/Guardian Signature:

Date: