Student Health And Emergency Information Form

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STUDENT HEALTH AND EMERGENCY INFORMATION FORM
School: circle HS/MS
Complete the following and return to school immediately. Contact School Nurse if you have questions with this form.
Student name___________________________________________________________________________ Grade_______________
Last
First
Middle
Address______________________________________________________ Student’s Primary Language _____________________
No. Street
Home Phone_____________________________Gender________________Date of Birth___________________________________
Does child have health insurance? Circle Yes / No
Name of Insurance Company________________________________________
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 name (printed)__________________________________________________________________________________
E-Mail Address_________________________________________ Home Address__________________________________________
Work Phone_________________________________________________ Cell Phone________________________________________
Father/Guardian name (printed)___________________________________________________________________________________
E-Mail Address _________________________________________Home Address__________________________________________
Work Phone __________________________________________________Cell Phone_______________________________________
IN CASE OF EMERGENCY AND NEITHER PARENT CAN BE REACHED, PLEASE LIST TWO NAMES AND PHONE NUMBERS OF
RELATIVE OR FRIEND WE MAY CONTACT WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD.
EMERGENCY NAME__________________________________________________Relationship___________________________
Home Phone ___________________________________________________Cell Phone___________________________________
EMERGENCY NAME__________________________________________________Relationship___________________________
Home Phone __________________________________________________ Cell Phone____________________________________
Physician’s Name__________________________________________________________________Phone______________________
Dentist’s Name____________________________________________________________________Phone______________________
Please list all the medications that your child takes ____________________________________________________________________
_____________________________________________________________________________________________________________
Please check all that applies to your child:
 Heart condition  Diabetes
 Asthma
 Seizure Disorder  ADD/ADHD
 Migraines
 Depression
Other__________________________________________________________________________________________________________________
Allergies (food, insects, medication, environment, (specify)_________________________________________________________________________
Does your child have an EpiPen? Yes No
Any other conditions that the School Nurse should know about? _____________________________________________________________________
Does your child:
 wear glasses
 wear contact lenses
 wear a hearing aid
 other corrective device
I give my permission for the school nurse to administer:  Acetaminophen Ibuprofen
Parent/Guardian signature_____________________________________________________________________Date____________________________
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 physician/counselor 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 emergency situation.
Parent/Guardian signature_____________________________________________________________________Date__________________________

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