Student Health And Emergency Information Form


Student I.D. #_____________________
2015 - 2016
Please complete the following information and return to school immediately. Contact school nurse if assistance is needed to complete form.
Student’s Name __________________________________________________________________________________________________
Address ________________________________________________________________________________________________________
Home Phone _______________________Grade ______ Sex _____DOB: _______________ Primary Language_____________________
Does your child have Health Insurance? _____ Yes _____ No
Dental Insurance? _____ Yes _____ No
Health Insurance Company ________________________________ Policy Number ___________________________
If you have no health insurance, the Commonwealth of Massachusetts has health insurance plans that will provide uninsured
children with affordable health care (Restrictions may apply). If you are interested in more information about this program,
please contact the school nurse. All communications will be confidential
Mother/Guardian/Other ___________________________________
Home Address ______________________________________________
Place of Employment _______________________________________ Work Address ______________________________________________
Home Telephone_______________________ Work Telephone _____________________Cell Telephone ______________________________
Father/Guardian/Other ___________________________________ Home Address ________________________________________________
Place of Employment _____________________________________ Work Address _________________________________________________
Home Telephone_______________________ Work Telephone _______________________Cell Telephone _____________________________
Name and Grade of sisters/brothers in school building __________________________________________________________________________
Please indicate names of friend/relative/neighbor who will assume responsibility and provide transportation for your child in case of
illness/injury/emergency evacuation:
Name ________________________________ Relationship ____________________ Daytime Phone __________________________
Name ________________________________ Relationship ____________________ Daytime Phone __________________________
In case of emergency, the school will attempt to contact parent/guardian before calling student’s primary healthcare provider (physician). Your
child will be transported by ambulance to an emergency care facility if deemed necessary.
Physician Name ___________________________Telephone Number ________________________Date of Last Examination _________
Dentist Name _____________________________Telephone Number ________________________Date of Last Examination_________
Preferred Hospital _________________________
Please list all medications that your child takes:__________________________________________________________________________
To better serve your child’s medical/physical/emotional/educational/social needs, please check the following that pertain to your child:
___Heart Condition
___Seizure Disorder
___Other (Specify) __________________________________________
___Allergies: To what? (food, insects, medication, environment) Specify_____________________________________________
Does your child have hearing problems? _____ Yes _____No
Left ear? _____ Right ear? _____
Hearing Aids? _____
Does your child have vision problems? _____ Yes _____No
Eyeglasses? _____
Contact Lens? _____
I understand that this information is confidential. However, federal law permits information in the school health records to be shared with school
officials on a “need to know” basis and with a very limited number of other persons, including those who could help in an emergency. In other
circumstances, my consent will be required. I give permission for the exchange of information between my child’s healthcare provider and the
school nurse.
Parents Signature _________________________________________________________Date_______________________________
Student Health and Emergency Information Form Rev. 2/17/15


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