Student Health And Emergency Information Sheet - Gates Intermediate School printable pdf download

GATES INTERMEDIATE SCHOOL

STUDENT HEALTH AND EMERGENCY INFORMATION SHEET

Please complete the following information below and return to school immediately.

Name: __________________________________________________________________________________________________________

First

Middle

Last

Street Address: ___________________________________________________________________________________________________

Number

Street

Apt #

City/State/Zip: ____________________________________________________________________________________________________

City

State

Zip

________________________________________________________________________________________________________________

Home phone

Gender

Birth date

Grade

Mother’s Name:

_________________________________

Father’s Name: _______________________________________

Mother’s Cell:

_________________________________

Father’s cell: _________________________________________

Daytime phone: __________________________________

Daytime phone: _______________________________________

My son/daughter is currently receiving the following medications (to be completed if not in violation of confidentiality):

________________________________________________________________________________________________________________

My son/daughter is known to have the following allergies:

________________________________________________________________________________________________________________

Please list any health concerns or issues:

________________________________________________________________________________________________________________

Family physician: _______________________________________ Phone: _____________________________________________

Health Insurance provider: ________________________________ Policy Number: _______________________________________

*If you do not have health insurance, Massachusetts has health insurance plans that will provide uninsured children with affordable health care

(restrictions may apply). Please contact the school nurse for more information about these programs. All communications will be confidential.

I give permission to have the school nurse or school personnel designated by the school nurse give the following medication in accordance with the

standing doctor’s order for the Scituate Public Schools prescribed by Dr. Stephen Lane, School Physician. (please check box):

Medication



Medication



Medication



Visine Eye Drops

Rhuligel or Calamine Lotion

Benadryl

Mylanta

Ibuprofen

Tylenol

Triple Antibiotic Ointment

Throat Lozenge

I understand that every effort will be made to contact me, however, IN CASE OF EMERGENCY, I hereby give permission to the physician or hospital

to secure proper treatment for and order injection, anesthesia or surgery for my child.

________________________________________

Relationship to Student

Parent/Guardian Signature

Student Health And Emergency Information Sheet - Gates Intermediate School

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