Family health information

Official form requiredThis online worksheet does not replace the Commonwealth form. Download the complete PDF, attach the family information, and take it to your child's provider.

Part I · family completed

Student and family

Fields marked with an asterisk are needed before downloading your entries.

Who is this form for?

Choose a child already connected to this family to fill information on file.

Maya MorganPreschool Threes · 5 dayTheodore “Theo” MorganToddlers · 3 dayBaby MorganFuture preschool requestAnother studentEnter their information manually.

School name Filled from your First Presbyterian Preschool account.Current grade Student last name Student first name Student middle name Date of birth Sex State or country of birth Main language spoken Street address City State ZIP code

Parent or legal guardian 1

Full name Phone Work or cell

Parent or legal guardian 2 optional

Full name Phone Work or cell

Emergency and insurance

Emergency contact name Emergency contact phone Emergency work or cell Hospital preference

Child's health insurance None FAMIS Plus (Medicaid) FAMIS Private / commercial / employer sponsored

Insurance company or plan details

Box 2

Medications and providers

List prescription, emergency, over-the-counter, and herbal medications used regularly.

Medication 1 name Dosage Time administered (home / school) Notes

Medication 2 name Dosage Time administered (home / school) Notes

Medication 3 name Dosage Time administered (home / school) Notes

Medication 4 name Dosage Time administered (home / school) Notes

Additional medications

Would you like to discuss confidential information with school staff? Yes No

Pediatrician / primary care providerName Phone Date of last appointment

SpecialistName Phone Date of last appointment

DentistName Phone Date of last appointment

Case worker, if applicableName Phone Date of last appointment

Authorization

Health information exchange

The official form contains the complete authorization language. Review it before choosing.

Provider authorization choiceI authorizeAllow the child's health care provider and designated school health authority to discuss or exchange information related to this form.I do not authorizeDo not allow this health-information exchange.

Parent or guardian printed name Date Interpreter name, if applicable Interpreter date

Print the official form and add the handwritten signatures it requires.