Complete 1 per child Ventura Elementary School Ventura/Garner-Hayfield Junior High School Annual Student Health Update
Student Name: _________________________________________ Gender: M F
Birthdate: _______________________ Grade: ______________ Building:___________ Parent/Guardian Name(s): ____________________________________________________ Family Doctor:
Medication Taken Regularly How Often Condition Medication is Taken For Allergies What Type of Reaction (food, environmental, latex, etc.)
Current Illness: List any illness, injury or surgeries occurring since last school year, including the date they occurred:________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Chronic Illness or Conditions that may affect school performance: List any health conditions such as asthma, migraines, seizures, diabetes, hearing problems, ADHD, behavioral, etc.:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Immunizations Received in the Last Year (Month/Year)
Other (list name of immunization and date received):
Please turn over and complete page 2 Complete 1 per child INSURANCE
_____ Private Insurance (List Name)__________________________________
_____ Other (List Name) ___________________________________________
PERMISSIONS
In case your child is ill or injured at school or during a school event out-of-town, and we think he/she needs medical attention, do you grant school personnel permission to do so? Yes________ No________ If student’s health care provider is not available, may we send him/her to another local provider? Yes________
I give my child permission to receive Tylenol/Acetaminophen for complaints of discomfort at school from the school nurse and trained school personnel at their discretion for this school year. Yes________ No________ Over-the-Counter Medication: I give permission for the use of cough drops, topical antibiotic ointment (Bacitracin), contact solution, Benadryl, or Caladryl as needed by the discretion of the health office and trained school personnel. Yes________ No________
MEDICATION POLICY I understand that my child can receive prescription medications at school through School Health Services. I understand that the medication must be in the original container with all the information current to what the child receives. I understand that a Medication Permission form must be signed and accompany the medication. This form can be obtained from the Health Services office in the school building your child attends.
NOTICE: The school does NOT assume financial responsibility for medical/dental bills incurred as a result of illness or school accidents. If needed, there is student accident insurance available for your child. The application can be picked up in a building office. NOTICE: Student’s health information is shared with appropriate staff in accordance with the District’s policy/procedure and applicable laws of confidentiality. Information is shared on a “need to know” basis with school personnel who supervise students.
Coastal Prestige Medical Services and Clinic 575 Price Street, Suite 313, Pismo Beach, CA 93449 Your Age: _____ First Name: _______________Last Name: Date: _______ Phone: ____________________Cell Phone: ____________________ Date of Birth : _______ PHYSICIAN/S: __________________________________________________________________________ When did your physician or nurse practitioner la
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Complete 1 per child