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St. Helen's School 2008-2009 Health History
Online forms are available for your use in registration. Please complete, print, sign (if applicable), and submit to the school office. If you have any questions, please contact the office at 382-8225.
Name   Class Room Teacher Home Address Date & Place of Birth   Sex Parent / Guardian   Phone Father's Occupation / Business Address   Phone         Mother's Occupation / Business Address   Phone         Family Physician   Phone Pediatrician   Phone Dentist   Phone     Check, if your child has had any of the following:             Chicken Pox German Measles Measles Poliomyelitis Scarlet Fever Whooping Cough Diptheria Mumps Pneumonia Rheumatic Fever Tuberculosis Contact with TB Check, if history of following, and describe below:         Asthma / Allergies Eye Condition Diabetes Heart Disease         Ear Condition Surgery Epilepsy Frequent Colds & Sore Throat     Please state if your child is receiving treatment at this time for any other condition: Yes No Growth and Development (to be completed by Kindergarten Children) Birth Weight   Delivery (Normal or Premature) Walked at age   Talked at Age ________________________________________________________ Parent / Guardian's SignatureDate