Student Health And Emergency Information Form printable pdf download

Student I.D. #_____________________

Teacher/Grade___________________________________

STUDENT HEALTH AND EMERGENCY INFORMATION FORM

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 __________________________________________________________________________________________________

Last

First

Middle

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 __________________________

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

___Diabetes

___Asthma

___Seizure Disorder

___ADD/ADHD

___Migraines

___Depression

___Other (Specify) __________________________________________

___Allergies: To what? (food, insects, medication, environment) Specify_____________________________________________

___Epi-Pen

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

Student Health And Emergency Information Form

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