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Today's Date:Schooled Health Center 201718 ENROLLMENT FORM Students name: (LAST)(FIRST)(FULL MIDDLE)Students school: Grade: Teacher/Homeroom: Students birthdate: Sex at birth: M F RACE: White Native
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How to fill out school-based health center enrollment
How to fill out school-based health center enrollment
01
Obtain the enrollment form from the school-based health center or download it from their website.
02
Fill in your personal information including name, address, phone number, and date of birth.
03
Provide information about your insurance coverage, including the name of the insurance company and policy number.
04
Indicate any medical conditions or allergies that the health center should be aware of.
05
Sign and date the enrollment form.
06
Submit the completed form to the school-based health center either in person or by mail.
Who needs school-based health center enrollment?
01
Any student who attends the school can benefit from school-based health center enrollment.
02
It is particularly useful for students who do not have access to regular medical care outside of school.
03
Students with chronic medical conditions or special healthcare needs may also benefit from enrolling in the school-based health center.
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