Arthur School Event

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* 1. Student Name

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* 2. Date of Birth:

Date

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* 3. Grade:

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* 4. Age:

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* 5. Gender:

Male

Female

Prefer not to answer

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* 6. Race:

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* 7. School:

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* 8. Social Security Number:

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* 9. Mother's Maiden Name:

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* 10. Address:

Address

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

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* 11. Medical Provider:

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* 12. Does your child have any health problems?

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* 13. Has you child been diagnosed with asthma?

Yes

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* 14. Is your child currently taking a steroid?

Yes

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* 15. List any medications your child is currently taking:

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* 16. Has you child had any previous reactions to vaccines?

Yes

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* 17. Please list any allergies your child may have:

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* 18. How did you hear about our services here at WCDHD?

Radio

Billboard

Physician

Friend/Family

Postcard

Facebook

WCDHD Waiting-room Educational Screen

Other (please specify)

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* 19. Does your child visit the dentist regularly?

Yes

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* 20. Date of child's last dental visit:

Date / Time

Date

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* 21. When was your child's last well child's exam/physical?

Date / Time

Date

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* 22. Parent/Guardian Name:

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* 23. Parent/GuardianContact Information:

Name

Employer

Address

Address 2

City/Town

State

ZIP/Postal Code

Country

Phone Number

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* 24. Parent/Guardian Date of Birth:

Date / Time

Date