School Nurse'S Student Health And Emergency Information printable pdf download

SCHOOL NURSE’S STUDENT HEALTH AND EMERGENCY INFORMATION

School__________________

Complete the following information and return to school immediately. Contact the School Nurse if you have questions about this form.

Student’s name ___________________________________________________ D.O.B.__________________ Sex ____________ Grade __________

Address ____________________________________Home Phone ________________________ Parent E-mail Address ____________________________

Mailing Address if different than above ________________________________________________ Student’s Primary Language _____________________

Is your child covered by Health Insurance ________Yes

________No

Insurance Company__________________ Policy # __________________

If you have no 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 communication will remain confidential.

Mother/Guardian/Other __________________________________ Home Address ________________________________________________________

Work Address _____________________________________ Work Phone ________________________ Cell Phone ________________________

Father/Guardian/Other ___________________________________ Home Address ________________________________________________________

Work Address _____________________________________ Work Phone ________________________ Cell Phone ________________________

Emergency contacts if parents/guardians cannot be reached in emergency. If your child is ill and you are unavailable, shall the school allow this person to

sign your child out of school?

_______________________________________________________________________________________

_______Yes _______ No

Name

Phone

Dismiss to care of this person?

_______________________________________________________________________________________

_______Yes _______ No

Name

Phone

Dismiss to care of this person?

_______________________________________________________________________________________

_______Yes _______ No

Name

Phone

Dismiss to care of this person?

In case of emergency, the school will attempt to contact parent/guardian before calling your child’s primary care provider (physician). Your child will be

transported by ambulance to an emergency care facility if necessary.

________________________________________________________

_______________________________

Physicians Name

Physician’s Phone

________________________________________________________

_______________________________

Dentist’s Name

Dentist’s Phone

Please list all medications that your child takes____________________________________________________________________________________

_________________________________________________________________________________________________________________________

Please check all that apply to your child

‫ٱ‬

Heart condition

Diabetes

Asthma

Seizure disorder

ADD/ADHD

Migraines

‫ٱ‬

Depression

Other (specify) _______________________________________________________________________________________

Known Allergies ________________________________________________________________________________________________________

Any other conditions that School Nurse should know about? ______________________________________________________________________

‫ٱ‬

Does your child

wear eyeglasses?

wear contact lenses?

wear a hearing aid ?

Other corrective device? ___________________

I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my

child’s health and safety needs. I give permission to exchange information with my child’s primary care physician for the purpose of referral, diagnosis and

treatment.

___________________________________________

_____________________

Parent/Guardian Signature

Date

I, the undersigned, as parent/guardian of the above named minor child, do hereby permit the hospital and its physicians to perform on this child any

procedures or treatment as may be deemed necessary in an emergency situation.

___________________________________________

_____________________

Parent/Guardian Signature

Date