Kingsport city schools health services

Kingsport City Schools Medical Form
This form is required for ALL After School and School Related Activities
A Parent/Guardian must complete ALL Items on this form.
***Additional forms will need to be completed if student takes Medication for Asthma or Allergies.
If questions, call the appropriate school nurse.
Name of Extra-Curricular School Activity:_______________________________________________________________
Student’s Name: ____________________________________________________________________________
(Last) (First) (Middle)

Student’s Address: __________________________________________________________________________
(No.) (Street) (City) (State) (Zip)
Student’s Date of Birth: ___________________________________ Grade: __________
Father’s Name: __________________________________________ E-Mail: _______________________
Father’s Address: ___________________________________________________________________________
Father’s Home Phone #: _______________ Work Phone #: _______________ Cell #: __________________
Mother’s Name: _______________________________________ E-Mail: _________________________
Mother’s Address: __________________________________________________________________________
Mother’s Home Phone #: ______________ Work Phone #: _________________ Cell #: _______________
Student’s Physician: __________________________________________ Phone #: ____________________
Health Insurance Company: _________________________________________________________________
Insurance Company Address: _________________________________________________________________
Group #: __________________________________ ID / Subscriber #: ________________________________
Social Security number of Card Holder: ________-________-________
Type of Insurance: Private______________________________ Group______________________________
No Medical Insurance at this time___________
(Other Than Those Listed Above)
Name: ________________________________________ Home Address: _____________________________ Home Phone #: _________________ Work Phone #: __________________ Cell #: _________________ Kingsport City Schools Medical Form. 2011 KINGSPORT CITY SCHOOLS 2010-2011 HEALTH SERVICES
Page 2
HEALTH HISTORY Student’s Name: _____________________________
Date of Birth:____________________________________
Drug Allergy (List) ________________________________ Food Allergy (List) _________________________________
Insect Bite Allergy (Life Threatening) _______________ Latex Allergy________________ Seasonal Allergy_________
Epi-Pen required for Allergy? ____________________Other Medications used for Allergy_______________________
Asthma_________ Inhaler required? __________Frequency used? ___________ Nebulizer required? ____________
Other Medical Problem(s) ____________________________________________________________________________
Current Medications: ________________________________________________________________________________
________________________________________________________ Last Tetanus Shot: ________________________
Details of Treatment / Activities to be Restricted (Requires Physician Note):__________________________________________
Medications/ Parental Permissions
Permission for Over-the-Counter Medications
I represent that I am the mother, father, guardian of the above child. I give my permission for KCS personnel to
administer, or assist in the self administration of the parent-provided medications that I have initialed.
____________________________________________________________________ MEDICATION
Bendadryl (Severe Allergies Only)
Questran (Cholestyramine)*
Permission for Prescription and All Other Over-the-Counter Medications
Before administering any prescribed or over-the-counter medication not on the above approved list the School Clinic must have on file: Completed Physician Form for Administration of Medication for each medication (over-the-counter &
prescribed medication). This form must be completed by your Physician.
Each medication must be in the original, unopened container with the original label listing the ingredients. The student’s name must be written on the container. Students are not allowed to share medications, including sunscreen and chapstick.
(The Physician Form for Administration of Medication can be obtained from the School Clinic and is good for one school year only).

Permission for Emergency Medical Treatment
In the event of an emergency and I am (or other emergency contact is) unable to be reached, I give permission for
emergency treatment in a hospital, including surgery requiring the use of an anesthetic.
Permission for Accompanying Physician: I give permission for any physician who is present at any after school
and/or school related activities to provide first aid/medical treatment to my child if necessary.
________________________________________________________________________________________ Kingsport City Schools Medical Form .2011


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