Required fields are indicated with a “*“.
Child admission ID: *
Health statement: *
Attach a Seizure Plan, including when to call 9-1-1 and if there is a medication to be given in the event of a prolonged seizure.:
Asthma Action Plan :
Food Allergy Safety Plan :
Environmental Allergy Safety Plan :
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which you are adhere to or if you are a member of, then please upload signed and dated affidavit stating the same:
Immunization Records :
If you are declining immunizations for reason of conscience, including religious belief, on the form described by Section 161.0041 Health and Safety Code submitted no later than the 90th day after the affidavit is notarized. Please upload the signed and dated scan copy of affidavit stating the same:
Vision Screening Report :
Hearing Screening Report :
If you are adhere to practices of a church or religious denomination or if you are a member of in which the vision or hearing screening conflicts with the tenets or practices, then please upload a signed and dated affidavit stating the same:
