Health Information Form

WES-DEL COMMUNITY SCHOOL CORPORATION STUDENT HEALTH RECORD

Dear Parent/Guardian,

Please complete the following form and return it to the school. It is necessary that the school health office and staff who work with your child have current information regarding his/her health status, history and/or special needs.

Health Information Form
Student's Name
 
**
 
Date of Birth
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Address
**
Address 1
**
Address 2
   
City                     State      Zip Code
Grade
Home Phone
 
 -  - 
(XXX)-XXX-XXXX
Cell Phone
 
 -  - 
(XXX)-XXX-XXXX
Other Siblings at Wes-Del
 
The below information will be given confidentially to staff members deemed necessary. I understand that by signing the emergency medical authorization permit, I am giving my permission to the nurse to share this info with the staff.
Allergies
 
Yes
No
Specify Allergy and Medications
 
Asthma
 
Yes
No
Medications Used and Date of Last Attack
 
Epilepsy/Seizures
 
Yes
No
Medications Used and Date of Last Seizure
 
Heart Condition
 
Yes
No
Medications Used and Specify Condition
 
Diabetes
 
Yes
No
Medication and Glucometer Used
 
Glasses/Contacts
 
Yes
No
Please check the following options that apply to your child:
 
Hearing Problems
ADD
ADHD
Hyperactivity
List all medications taken on a regular basis.
 
If your child has any special needs, a physician's order IS REQUIRED at the beginning of each new school year.
 
Special Diet/Food Allergy
Restrictions in Physical Activity
Student Needs to Carry Medication
 
 
 
EMERGENCY MEDICAL AUTHORIZATION PERMIT

In case of accident or serious illness, I request the school to contact me. If the school officials are unable to contact me, I hereby authorize the school to telephone the physician indicated below and to follow his/her instructions. If it is not possible to contact the physician, the school may make whatever arrangements necessary.
Mother's Name
 
 
Work Phone
 
 -  - 
(XXX)-XXX-XXXX
Father's Name
 
 
Work Phone
 
 -  - 
(XXX)-XXX-XXXX
Doctor's Name
 
 
Doctor's Phone
 
 -  - 
(XXX)-XXX-XXXX
Other Emergency Names and Phone Numbers
 
I have read and understand the above form and that by selecting the "Yes" option that I am the parent or guardian listed below.
 
Yes
No
Authorized Parent or Guardian:
 
 
Date
 
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When you have completed this form, please select the Send Now button below.
 


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