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School Year: ____________
Student’s Name: __________________________________________________________ Grade: _____________ Father’s Name: __________________________________ Mother’s Name: ________________________________ Address: ____________________________________________________________________________________ Home Phone: _________________Father’s Cell: _________________ Mother’s Cell : _______________________ Student lives with?  Both Parents  Mother  Father  Guardian  Foster Home Please number in order of preference your desired procedure in the case of illness or injury: ( ) Contact Father’s Employer: ______________________________________ Phone: _____________________ ( ) Contact Mother’s Employer: _____________________________________ Phone: _____________________ ( ) Emergency Contact Person: _____________________________________ Phone: ______________________ ( ) Emergency Contact Person: _____________________________________ Phone: ______________________ * One of the above must be available to pick up the child if he/she has to go home.
Family Doctor: _________________________________________ Phone: ________________________________ Family Dentist: _________________________________________ Phone: ________________________________ Does this child have food allergies?  No  Yes If yes, please specify: ___________________________________ Type of reaction: ________________________ Does this child have drug allergies?  No  Yes If yes, please specify: ___________________________________ Type of reaction: ________________________ Is an Epi-pen required/prescribed by a doctor?  No  Yes Does your child carry an Epi-pen with him/her?  No  Yes If yes, Doctor’s Order (school form) is needed. Parent is responsible for providing the Epi-pen. Does this child have asthma?  No  Yes If yes, list triggers/symptoms: ________________________________ Has your doctor prescribed an inhaler?  No  Yes If yes, list name of inhaler: __________________________ If yes, Doctor’s Order (school form) is needed. Parent is responsible for providing medication to the school. Does this child have chronic or medical conditions/illnesses? If yes, check:  Seizures  Diabetes ( Type 1 or  Type 2)  Cardiac Condition  Other, specify ____________________________________________________ Please list any other important information to help us better care for your child while at school: _______________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Please list medications & reason for taking at home: _________________________________________________ Please list medications & reason for taking at school: _________________________________________________ * All prescription medications that need to be given during school hours must have a Doctor’s Order (school form) and be kept in the nurses’ office. The following are the approved over-the-counter medications that may be administered at school. Please check yes or no as to whether your child may be given these medications: Medication/Dosage
Decongestant tablets/liquid, as directed for weight & age Medical Permission for School Health Services
 I hereby give permission for my child to receive the following medical attention as part of the state-mandated  Height and weight annually; K – 12  Scoliosis screening examinations; 6 & 7  Puberty informational talk and video; 5  Hearing screening; K, 1, 2, 3, 7, & 11  Each year the school nurse prepares a confidential list that includes students who have significant health concerns. This confidential list is shared with staff for the sole purpose of protecting the health and well being of the student. By signing below you allow the nurse to share any information deemed appropriate.  If a parent cannot be notified, and emergency care is necessary, I hereby give my permission for this student to be transported to the nearest hospital and I give permission for the hospital to give emergency treatment as may be needed. I will assume responsibility for fees incurred by such an emergency. Parent’s/Guardian’s Signature: __________________________________________ Date: _______________________

Source: http://lccs.cc/files/Admissions%20Files/Medical%20Release.pdf

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