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Get and Sign Diabetes Intake Form
_____________________________
Parent/Guardian 2: ________________________________ Contact Information: _____________________________
Name of physician treating student’s diabetes: _________________________ Phone Number: __________________
Health Insurance: ☐ Private
☐ Medicaid/KanCare
Medical alert jewelry worn? ☐ Yes ☐ No
☐ Currently without insurance
IEP? ☐ Yes ☐ No
Current 504 Plan? ☐ Yes ☐ No
Mode of transportation to and from school?...
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