Student Health Information - School Form - 2015 (Page 2 of 2) in pdf

Student Health Information - School Form - 2015 Page 2

SPS – STUDENT HEALTH INFORMATION continued.

MEDICATIONS

List any medications taken by student:|

Medication Taken: _____________________________ For___________________________________ ☐At Home

☐At School

Medication Taken: _____________________________ For___________________________________ ☐At Home

☐At School

Medication Taken: _____________________________ For___________________________________ ☐At Home

☐At School

Students requiring medications during the school day (herbal, over the counter, or prescription) MUST have a written provider order

and written parent consent and health care provider must be on file. Contact your school office for MEDICATIONS AT SCHOOL form

and MUTUAL EXCHANGE form.

SHARING HEALTH CARE INFORMATION

In order to provide a safe and healthy environment for your child, the school nurse may need to share information about your student’s

health condition with teachers and essential school staff. If you have questions, please contact your school nurse or Health Services.

CONTACT INFORMATION

Please provide correct & current contact numbers, and update with School Nurse if needed.

Name of Health Care Provider: _____________________________________________________Phone: ________________________

Name of Dentist: ________________________________________________________________Phone: ________________________

1. Parents/Guardians

2. Parents/Guardians

Names:

Home phone:

Cell phone:

Work phone:

Email:

Additional Information:

_________________________________________________

Student’s Name

_________________________________________________

Your Name (printed)

Signature

_________________________________________________

Relationship to Student

Today’s Date

Nurse Review Date/Initial:____________________

HealthRegFORM0415

Form adapted w/permission BSD&ESD

Student Health Information - School Form - 2015 Page 2