• Student Health History & Emergency Medical Treatment Consent Form

  •  /  /
    Pick a Date
  • Parent/Guardian/Emergency Contacts

  •  -
  •  -
  •  -
  • Insurance Information:

  • INDICATE IF STUDENT HAS BEEN DIAGNOSED BY A LICENSED HEALTHCARE PROVIDER WITH ANY OF THE FOLLOWING:

  • If your child has a life-threatening condition, state law requires that medication and/or treatment orders from your licensed healthcare provider, and an Emergency Plan prepared by the School Nurse, must be in place before your child can attend school.

  • Health Condition

    Indicate YES or NO
  • Medication Allergies

  • Food Allergies


  • Allergy to Bees Stings

  • Allergies (other)

  • Asthma

  • Diabetes

  • Seizure Disorder

  • Neurological Disorder

  • Heart Condition

  • Blood Disorder

  • Cancer

  • Bowel/Bladder Issues

  • Migraine Headaches

  • Bone/Muscle Problems

  • ADD/ADHD

  • Mental Health Behavioral Issues

  • Wears Glasses/Contacts

  • Hearing Loss

  • Other Serious Illness

  •  /  /
    Pick a Date
  • Serious Injury

  •  /  /
    Pick a Date
  • Surgery

  •  /  /
    Pick a Date
  • Other Medications Taken at Home

  • The information on this form may be shared confidentially with school staff and emergency responders as needed. In the event of a medical emergency with my child, I understand every effort will be made to inform me. If emergency care is needed, I authorize qualified professionals to provide assessment, diagnosis and any necessary emergency treatment. I understand that the school district assumes no financial liability for expenses incurred due to accident, injury and/or unforeseen circumstance.

  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm