2025-2026 Health Questionnaire (Kindergarten and New Student)

Health Questionnaire (One time for each student)

Student's Last Name*

Answer required for "Student's Last Name"

Student's First Name*

Answer required for "Student's First Name"

To Be Completed by Parent/Guardian:

Please check yes or no for each condition listed below. Please explain all yes responses.

Allergy*

Answer required for "Allergy"

Yes

Explain

Answer required for "Explain"

Asthma*

Answer required for "Asthma"

Yes

Explain

Answer required for "Explain"

Chicken Pox*

Answer required for "Chicken Pox"

Yes

Explain

Answer required for "Explain"

Diabetes*

Answer required for "Diabetes"

Yes

Explain

Answer required for "Explain"

Diphtheria*

Answer required for "Diphtheria"

Yes

Explain

Answer required for "Explain"

Ears/Ear Infections*

Answer required for "Ears/Ear Infections"

Yes

Explain

Answer required for "Explain"

Epilepsy*

Answer required for "Epilepsy"

Yes

Explain

Answer required for "Explain"

Handicaps*

Answer required for "Handicaps"

Yes

Explain

Answer required for "Explain"

Hepatitis*

Answer required for "Hepatitis"

Yes

Explain

Answer required for "Explain"

Mononucleosis*

Answer required for "Mononucleosis"

Yes

Explain

Answer required for "Explain"

Mumps*

Answer required for "Mumps"

Yes

Explain

Answer required for "Explain"

Measles*

Answer required for "Measles"

Yes

Explain

Answer required for "Explain"

Operations*

Answer required for "Operations"

Yes

Explain

Answer required for "Explain"

Pneumonia*

Answer required for "Pneumonia"

Yes

Explain

Answer required for "Explain"

Poliomyelitis*

Answer required for "Poliomyelitis"

Yes

Explain

Answer required for "Explain"

Rheumatic Fever*

Answer required for "Rheumatic Fever"

Yes

Explain

Answer required for "Explain"

Rubella*

Answer required for "Rubella"

Yes

Explain

Answer required for "Explain"

Scarlet Fever*

Answer required for "Scarlet Fever"

Yes

Explain

Answer required for "Explain"

Seizures*

Answer required for "Seizures"

Yes

Explain

Answer required for "Explain"

Severe Illness*

Answer required for "Severe Illness"

Yes

Explain

Answer required for "Explain"

Severe Injuries*

Answer required for "Severe Injuries"

Yes

Explain

Answer required for "Explain"

Tuberculosis*

Answer required for "Tuberculosis"

Yes

Explain

Answer required for "Explain"

Whooping Cough*

Answer required for "Whooping Cough"

Yes

Explain

Answer required for "Explain"

Other

Answer required for "Other"

Has your child had an infectious/communicable disease other than those listed above?*

Answer required for "Has your child had an infectious/communicable disease other than those listed above?"

Is there any other information about your child’s health that you think the school should know which may be relevant to your child’s health and safety or the health and safety of others in the school?*

Answer required for "Is there any other information about your child’s health that you think the school should know which may be relevant to your child’s health and safety or the health and safety of others in the school?"

Please list any condition that should be considered in planning your child’s school day:

Answer required for "Please list any condition that should be considered in planning your child’s school day:"

To the best of my knowledge, the above information is complete and accurate. I acknowledge that I have a continuing obligation to inform the school of any changes in my child’s health status that are relevant to the information requested by this form.*

Parent Signature (Typing your full name will be regarded as your signature.)

Answer required for "To the best of my knowledge, the above information is complete and accurate. I acknowledge that I have a continuing obligation to inform the school of any changes in my child’s health status that are relevant to the information requested by this form."

Today's Date*

Answer required for "Today's Date"

Parent Signature (Typing your full name will be regarded as your signature.)

Answer required for "Parent Signature (Typing your full name will be regarded as your signature.)"

Today's Date

Answer required for "Today's Date"

Blackhawk Christian School does not discriminate on the basis of race, color, sex, nationality, or ethnic origin in its admission, education, financial, or employment policies.

Please fix the highlighted areas below before submitting.

2025-2026 Health Questionnaire (Kindergarten and New Student)