Physical+Education+Request+for+Medical+Information

. **85-05 144th Street** ** Patrick Burns- Principal ** ** Attention Parent/Guardian: ** The health and safety of the students are our primary concern at Van Wyck Middle School. Communication and cooperation between the Physical Education staff and the parents/guardians is vital. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 prohibit Van Wyck M.S. from requiring an individual to complete a health history. However, students may have health concerns our staff should be made aware of. Please communicate in writing any information that we should know about. Your input will help us protect the safety of your child.
 * VAN WYCK MIDDLE SCHOOL M.S.217 **
 * Jamaica****, N.Y. 11435**
 * Re: Medical Records/Physical Education **

Thank you for your attention,

Mr. Patrick Burns Principal Medical Condition : __Asthma **No** inhaler used __ _Asthma inhaler used please specify when: Other Concerns:
 * If there is a medical concern, please tear off and have your child return to the Physical Education Department on their next scheduled class. **
 * If there is a medical concern, please tear off and have your child return to the Physical Education Department on their next scheduled class. **

Parent/Guardian Signature: _ __Date:__ ** RETURN TO THE **
 * PHYSICAL EDUCATION DEPARTMENT **