Annual Student Health Information & Emergency Consent To ensure the safety of your child, this form must be completed annually and returned to the school office before the start of the academic year. I. Student InformationStudent Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Gender Male Female Grade / Class(Required)Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code II. Emergency Contacts (Parent/Guardian)Primary Contact Name(Required)RelationshipPhone (Cell)(Required)Phone (Work)Secondary Contact NameRelationship (Secondary)Phone (Cell) (Secondary)Phone (Work) (Secondary)III. Medical HistoryPlease check if your child has a history of any of the following. If YES, please explain.Asthma Yes No If Yes, does student carry an inhaler? Yes No Asthma Details / TriggersSevere Allergy (Anaphylaxis) Yes No Allergen(s)Does student carry an EpiPen? Yes No Seizure Disorder Yes No Type / FrequencyDiabetes Yes No Diabetes Type Type 1 Type 2 Insulin Dependent? Yes No Seasonal/Environmental Allergies Yes No TriggersHearing/Vision Problems Yes No Hearing/Vision Aids Glasses Contacts Hearing Aid ADD / ADHD Yes No ADD/ADHD Notes (if applicable)Other Conditions (please specify)IMPORTANT: If you answered YES to Asthma, Severe Allergy, Seizures, or Diabetes, you must submit a specific Emergency Action Plan signed by your physician.Upload Emergency Action Plan (PDF) Drop files here or Select files Accepted file types: pdf, Max. file size: 250 MB. IV. MedicationsDoes your child take any medication on a daily basis at HOME? No Yes If Yes, please list name/doseWill your child need to take medication at SCHOOL? No Yes Note: If Yes, you must complete the separate “Authorization for Medication Administration at School” form.V. Healthcare Provider InformationPediatrician/PCP NamePediatrician/PCP PhoneDentist NameDentist PhoneHealth Insurance CarrierPolicy #VI. Emergency Authorization & ConsentRelease of Information(Required) I authorize the school nurse or designated staff to share this medical information with appropriate school personnel (teachers, bus drivers, coaches) on a need-to-know basis to ensure my child's safety. Emergency Treatment(Required) In the event of a medical emergency, I hereby give permission to school staff to provide First Aid/CPR and to arrange for transportation to the nearest hospital via Emergency Medical Services (911). Medical Care(Required) I authorize the attending medical professionals at the hospital to administer necessary emergency medical treatment if I cannot be reached immediately. Parent / Guardian Signature(Required)Signature Date(Required) MM slash DD slash YYYY
