ANNUAL HEALTH CENSUS FORM
FOR STUDENTS ATTENDING MANKATO AREA PUBLIC SCHOOLS
(TO BE COMPLETED EACH SCHOOL YEAR TO UPDATE STUDENT HEALTH RECORD)
Student Name:
LAST FIRST MIDDLE
Date of Birth:
School: Grade: School Year:
Name of Health Care Provider: Clinic:
If you would like to schedule a conference with the Licensed School Nurse to discuss any health concerns,
please contact the Health Service office at your child’s school.
Does student have a medically diagnosed condition, such as:
Diabetes Asthma/RAD Seizures Life-threatening Allergy None
Other Explain:
*REMINDER: Individual care plan forms for students with chronic health conditions, including life-
threatening allergies, asthma, diabetes, and seizures, are available on the Health Service page of the district
website.
Does student have any shunt or implant device?
Yes No
If yes, explain:
Is student taking any medication(s)? Yes No Name of medication(s)
Will student take medication(s) at school? Yes No
*REMINDER: All prescription and non-prescription medications at school (including inhaler, insulin, and
epinephrine auto-injectors) require a signed Mankato Area Public and Non-Public Schools “Consent for
Administration of Medication” form which can be found on the Health Service page of the district website.
ALL MEDICATIONS MUST BE BROUGHT IN BY PARENT/GUARDIAN.
● At the discretion of the Licensed School Nurse/designee, the above health information can be shared with
appropriate school and Emergency Response personnel to provide for student’s health and safety needs while
at school.
● You may refuse to supply the requested personal information; however, it may result in an incomplete health
and safety plan for your student.
● If your child rides the school bus, it is your responsibility to inform the bus company of your child’s health
condition and plan.
● If your child participates in before and/or after school activities, it is your responsibility to inform them of your
child’s health condition and plan.
●
By typing my name on the line below I understand and acknowledge that electronically signed documents will be valid and enforced in the
same manner as a hand-signed document and that a record or signature will not be denied legal effect or enforceability under law solely
because it is an electronic form.
Parent/Guardian Signature Date
Revised 05/18 dr
