Student Information Form Page 2
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1
2
3STUDENT INFORMATION --- NURSE’S OFFICE
S
: _____________________________ ________________________________ ________
TUDENT
First Name
Last Name
5-digit ID
H
T
_____________________ G
: ___
B
: _____________
OMEROOM
EACHER
RADE
IRTHDATE
MALE
FEMALE
P
A
: ______________________________________________________
ZIP _________________
HYSICAL
DDRESS
S
D
: _______________________________________
H
P
: _____________________
UB
IVISION
OME
HONE
S
R
: ______________________________
EMAIL: _________________________________
TUDENT
ESIDES WITH
P
A
S
P
C
(Use name on Driver’s License)
ERSONS
UTHORIZED TO PICK UP
TUDENT AND
HONE
ONTACT INFORMATION
Parent/Guardian: ____________________________________ Primary #: _______________
Other #: ____________________
Parent/Guardian: ____________________________________ Primary #: _______________
Other #: ____________________
Name: ____________________________________________ Phone: __________________
Relationship: ________________
Name: ____________________________________________ Phone: __________________
Relationship: ________________
S
P
(We are concerned with the safety of your child, please check appropriate box)
TUDENT
ROTECTION
There is not a problem at the present time with mother and/or father picking child up at school.
There is a problem with (name) ______________________________ picking child up at school.*
(*Note: If checked, custody/legal court documents must be on file in the school office.)
List all brothers and sisters living in the household:
Name: ____________________________
Age: _______
Name: _______________________________ Age ___ Name: ____________________________
Age: _______
Name: _______________________________ Age ___ Name: ____________________________
Age: _______
H
I
: list any conditions such as asthma, heart problems, diabetes, epilepsy, severe allergies,
EALTH
NFORMATION
ADD or any chronic health condition pertinent to this student.
_____________________________________________
D
S
: G
C
Y
N
H
A
:
Y
N
OES
TUDENT WEAR
LASSES OR
ONTACTS
ES
O
EARING
ID
ES
O
M
student is taking/reason: ________________________________________________________
EDICATIONS
All other over-the-counter medications–including but not limited to Tylenol, Ibuprofen, Aleve, cough drops, antibiotic
ointment, oragel – must be provided and transported to and from the school BY THE PARENT, in its original
container and a medication permission form must be filed with the school nurse.
___
All medication must be in its original & labeled container and brought to clinic by
INITIALS
parents/guardian. No medication is allowed on the bus.
___
At the nurse’s discretion, only the following clinic medications may be used: Hydrogen Peroxide, Vaseline,
INITIALS
and Calamine lotion. Please notify the school if your child has a condition that will prohibit the use of such items.
D
’
N
: _____________________________________
Phone Number: ____________________
OCTOR
S
AME
IT IS YOUR RESPONSIBILITY TO NOTIFY THE OFFICE OF ANY CHANGES ON THIS FORM.
I, the undersigned, do hereby authorize the officials of Montgomery ISD to contact directly the persons named on this
card, and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency. The
school officials are hereby authorized to take any action that is deemed necessary in their judgment, for the care of my
child. I will not hold the school district responsible for the emergency care and/or transportation of my child.
Date: _________________________________
Parent Signature:
The student must remain free of fever for 24 hours before they are allowed to return to school.
Note:
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