ONGOING HEALTH CONCERNS
Name of Student:  	
Date of Birth: 	Grade: 	Building   	

If your child has had or currently has ongoing health concerns, please complete this form and return it to the school nurse. If you have questions or concerns you may call her.
The nurses’ contact information is:

Denise Howe, RN	Pat Tresemer, RN
Centerville Community School District		Centerville Community School District 1800 S. 11th Street	600 CHS Drive
Centerville, IA 52544	Centerville, IA 52544
641-856-0628 or 895-3809	641-856-0806 or 895-8143
fax: 641-856-0641	fax: 641-856-0809
email: jackie.kelly@gpaea.k12.ia.us	email: pat.tresemer@gpaea.k12.ia.us Your health provider has diagnosed the problem as:
This condition is currently being treated by 	. Phone #   	
Has hospitalization been needed in the past year? 		NO 	YES Are special measures needed at school? 	NO 	YES If so, list them

If medications are needed please list them and what time of day they are taken:

If medications must be taken during the school day, please fill out the authorization form available on this website or contact the school nurse or building office for the appropriate authorization form. Bring the completed form and the medication to the building office.

Remember to contact the school immediately of changes in phone numbers, addresses, responsible emergency contact person, or doctor.

Signature of parent/guardian	date