11_12_nrhs_blank_health emergency form

Nashoba Regional High School
Return to School Nurse
School Health Services: Student Emergency and Health Record
School Year 2011/2012
Sept. 2011 Grade:_______
Student Name
Date of Birth
Birthplace
Mother/Guardian
Employer
Father/Guardian
Employer
Parent/Guardian Email
SIBLINGS
TELEPHONE NUMBERS: Include extensions and other prompts
Work/Daytime Phone Cell
Mother/Guardian 1
Father/Guardian 2
With whom does the child reside?
Name & Address, if different
Primary Language at Home
EMERGENCY CONTACTS: LOCAL persons to be notified in case of an emergency or illness, when you are unable to
be reached. Your child will only be released to the care of those listed below.
Relationship
Home/Daytime Phone Work, if different
** NOTIFICATION REGARDING STUDENT IDENTIFICATION: Throughout the year, faculty, staff, and the
administration attempt to acknowledge and celebrate the achievements, work and contributions of students and community
members. We do this through the display of work, verbal recognition, and through various printed, electronic, recorded, and
photographic mediums. Also, your son's name and phone number WILL be listed in a student directory unless you circle the
following:
Do NOT include my child's information or photograph.
**Under the No Child Left Behind Act, name, address and phone number of secondary students will be released to the U.S.
Military unless you indicate that you do NOT want your child's information released. Circle DO NOT RELEASE, if
applicable.
HEALTH INSURANCE: Name of Company
Mass Health
No Insurance
If you have no health insurance, Massachusetts has health insurance plans that will provide uninsured children withaffordable health care (restrictions may apply). Please contact the school nurse for more information about these programs.
All communications will be confidential.
CONFIDENTIAL INFORMATION: I grant permission to the school nurse, athletic director, and/or trainer to share health
information about my child, on a need to know basis, with his/her teachers, coaches, and support staff. YES NO
MEDICAL RELEASE: I grant to the Nashoba Regional School District personnel, the right to obtain emergency medical
treatment for my child during the period of the school year. I give permission for ambulance transport to the nearest hospital.
Payment for any and all medical treatment is the financial responsibility of the parent/guardian.
Parent/Guardian Signature
Please turn page over to complete side 2 of this form.
HEALTH HISTORY: LIFE THREATENING ALLERGIES
Please indicate if your child has a
physician verified allergy to any of the following. *If yes, please provide official
documentation by your child's physician and an Emergency Care Plan to the school nurse at the beginning of the school year.
Written prescriptions are required for all Epi Pens, Benadryl and inhalers.
Bee Stings
Medication
Describe your child's reaction.
Emergency Care Plan
Does ___________ carry his/her own Epi Pen? Indicate treatment for allergic reaction at school. Illness/Chronic Conditions: Indicate if your child has experienced any of the following. If yes, please explain condition below.
HEALTH CARE PROVIDERS:
DENTAL: Dental Insurance
Does your child visit the dentist every six months? Yes No Date of last exam.
SPORTS: Do you know of any reason your child should not participate in sports? Please indicate.
***A physical exam is required annually for school sports at the middle and high school level.
MEDICATIONS: Please list prescribed and over the counter medications your child takes. Include herbal treatments.
MEDICATION ADMINISTRATION: Per NRSD protocol, and with your signature below, our school nurses
may dispense the following over-the-counter medications after assessment of your child:
Ibuprofen (Advil, Motrin)____ Acetaminophen (Tylenol) ____ Antacid (Tums)____ Benadryl ____
**To DENY permission for the medications listed above, please check here. _____
All other medications require a written prescription from your physician and your signed permission.
Please note: The above OTC medications may be given only once during the school day. Also, the school nurse may use first aid treatments,
including topical ones, to treat allergic rashes, insect bites, toothaches, minor wound infections and minor burns unless otherwise indicated by
parent/guardian.
Parent/Guardian Signature

Source: http://www.nrsd.net/assets/files/Health%20Office/11_12_NRHS_Blank_Health_Eme.pdf