Name:                                                                Grade: ______

Birth Date: __________________________    Team: ______

Home Address:                                                                                                                                                                                                                                                                      

Home Phone:                                                                         

(Message # & Name if no phone)

Child lives with (check all that apply

___Parents     ___Grandparents

___ Dad          ___ Step Parent

­­___ Mom         ___ Guardian

___ Other                                __

Other Children in Home

(Name and Age):

Father’s Name:                                                                      

Mother’s Name:                                                                      

Step Parent’s Name:                                                             

Significant Other in Home:                                                     

Guardian:                                                                               

Medical Information                                     Date of last:                           Next scheduled:

Child’s Doctor: ­­_____________________­­_   medical exam __________   medical exam ­­­_________

Child’s Dentist: ­­­­­­­­­­­­­­______________________   dental exam ­___________   dental exam __________

Medical Insurance: ­­­­­                                                                                                                             ___

Child’s Allergies:                                                                                                                                 ___

                                                                                                                                                            ___

Location of Adult Family Members During School Hours

Name:                                                                                     Home during day _____ Work ______

Place of Employment:                                                                                         Phone: ____________

Name:                                                                                      Home during day ­­­_____ Work ______

Place of Employment:                                                                                          Phone: ­­­____________

Name and phone number of relatives or friends who are willing to transport and assume responsibility of the student in case of illness or emergency, if a parent cannot be reached.

Name:                                                                         Relationship: _______________Phone: ­­­____________

Name:                                                                         Relationship: ­­­­­­­­­_______________Phone:­­­­ ­­­­­­­­­____________

* Please notify these people that you have listed them as emergency contacts for your child.

Is anyone forbidden to access this child by court order?

_______ No

_______ Yes – please bring a copy to school for your child’s records.

List any medications your child currently takes at home:                                                                                                                                                                                                                                                                                                                                                                                         

List any significant, continuing, or new health problems that your child has (example: epilepsy, asthma, diabetes, attention deficit, allergies, etc.)                                                                                                                                                                                                                                        

Would you like your child’s condition included on the confidential Health Problem List given to teachers:  ______ Yes, I feel this is important for my child’s teachers to know.

                 ______ No, I do not feel that this information needs to be shared with my child’s teachers.

Please list any other information that might be helpful in providing health care for your child:

Summer immunizations (name and date):                                                                                                                                                                                                                                                  

SPECIFIC NON-PRESCRIPTION MEDICATION FORM

Parents have requested that they be given the opportunity at the beginning of the year to give permission for their student to receive the non-prescription medications listed below, so that they will not need to rewrite notes or sign repeat forms during the year.  Therefore, we give all parents the opportunity to do so.

Please circle your choice for each of the following medications:

Name:                                                                        

                        Permission

            Cough drops------------------- Yes     No

            Acetaminophen (Tylenol) -- Yes     No

            Other                                                  

Parent Signature:                                           

   Cough drops need to be sent with students to school and brought to the Health Office.  The school will not provide cough drops.  If your child has received a medication before school, please send a note with the name of the medication, time and the reason so we are aware of it in case your child visits the Health Office later in the day.

   Any other prescription or non-prescription medication that your child needs to take must be brought to the Health Office in the original container with a note from home.

***EMERGENCY RELEASE***

In the event of an emergency, I request the school to contact me.  If they are not able to reach me and emergency care is necessary, I give permission to the school personnel to seek emergency medical care, including transportation to and care at the closest emergency facilities and I assume financial responsibility for such.

Signature of Parent/Guardian: