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860-437-4550
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School-Based Health Center (SBHC) Registration/Medical Appointment Request
Student Name:
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Student DOB:
(Required)
MM slash DD slash YYYY
Assigned Sex
Male
Female
Other
Language Spoken at Home:
What school does your child attend or plan to attend:
(Required)
Bennie Dover Jackson Middle School (New London)
Catherine Kolnaski STEAM Magnet School (Groton)
C.B. Jennings International Elementary Magnet School (New London)
Ella T. Grasso Technical School (Groton)
Fitch High School (Groton)
The Friendship School (Waterford)
Gales Ferry School/Juliet W. Long School (Gales Ferry/Ledyard)
Gallup Hill School (Ledyard)
Groton Middle School (Groton)
Ledyard High School (Ledyard)
Ledyard Middle School (Gales Ferry/Ledyard)
Mystic River Magnet School (Groton)
Nathan Hale Arts Magnet School (New London)
New London High School (New London)
Northeast Academy (Groton)
Regional Multicultural Magnet School (New London)
Stonington High School (Pawcatuck)
Thames River Magnet School (Groton)
West Vine Elementary School (Pawcatuck)
Winthrop STEM Magnet Elementary School (New London)
Other
Is the student under the age of 18?
(Required)
Yes
No
Parent/Guardian Name:
(Required)
First
Last
Parent/Guardian Cell Phone Number:
(Required)
Parent/Guardian Email:
(Required)
Student Cell Phone Number:
(Required)
Student Email:
(Required)
Would you like to request a medical appointment?
(Required)
Yes
No
Services requested
(Required)
(check all applicable)
Physical Exam (Annual, School Entry, Sports)
Flu Vaccine
Other vaccination
Other service
Disclaimer:
We are currently receiving a high volume of requests for services. Please expect return contact for scheduling in
5 business days
. Appointments can be scheduled by calling (860) 437-4550, option 3 to speak with a medical services representative. For urgent or emergent requests please call 911, or go to the nearest emergency department for assistance.
