Student Health Form and ATP

RAINIER CHRISTIAN SCHOOL DISTRICT STUDENT HEALTH INFORMATION

The following information is needed to plan and be prepared for any needs or emergency situation should one arise during school attendance.
Student Name *
Birth Date *

Month Day Year
Date
Grade *
Campus *
Gender *

Male Female
Parent Email *
example@example.com
Emergency Contact: In sequence, in case of emergency:
1. Name *
Phone *
Relationship *
2. Name *
Phone *
Relationship *
3. Name *
Phone *
Relationship *
Medical Information:

A. HEALTH HISTORY: Please describe any significant or chronic medical problems such as asthmas, hay fever, diabetes, heart condition, seizure disorder, headaches, orthopedic, vision, surgeries, emotional problems, chronic colds or infections, speech difficulty, nose bleeds, etc.
Diagnosis
Date of Onset & Treatment

Month Day Year
Date
Does student wear contact lens?
Does student wear glasses?
Last Eye Exam
B. ALLERGIC TO: Medications (name):
Medications (name)
Foods
Insects
Plants
Others
Please describe the allergic reaction and necessary treatment
C. MEDICATIONS: Please list medications (and dosages) your child takes on a regular basis.
D. Was there a health problem and/or handicap present at birth?
At what age was diagnosis made?
Diagnosis
Physicians or agencies which made diagnosis
Physical Education Activity
If limited, please explain
E. Physician *
Address
Phone *
Dentist *
Address
Phone *
Hospital of Choice *
Insurance Company *
Policy # *
Group # *
MEDICAL AND/OR EMERGENCY RELEASE:
In the event of an emergency and all attempts to reach me/U.S. guardian have failed, and school authorities judge that immediate observation and/or treatment is necessary, I authorize and direct that my child receive such care as is necessary. Emergency treatment may require notification of an Emergency Aid Unit (911 Further treatment, based upon medical evaluation and recommendation, may be given. I understand that I assume responsibility for any payment of services rendered if required.
Signature of Parent/Guardian *

Clear
Print Name *
Date *

Month Day Year
Date
PERMISSION TO ADMINISTER MEDICATION:
I understand that in the event my child needs to take over-the-counter or prescription medication, I must complete the Authorization for Administration of Oral Medication at School form.
Signature of Parent/Guardian *

Clear
Print Name *
Date *

Month Day Year
Date

Authorization to Pick Up Student

The following individuals are hereby authorized to pick up my child without further authorization and may also be contacted in the event of an emergency.

Please include both the address and phone number for each individual. Your student will only be released to the people listed below. Please let your pick-up person know that they will be asked for ID before your child is released to them. This is for everyone's safety.
1. Name
Relationship
Phone
Address

Address

Street Address Line 2

City

Zip Code
2. Name
Relationship
Phone
Address

Address

Street Address Line 2

City

Zip Code
3. Name
Relationship
Phone
Address

Address

Street Address Line 2

City

Zip Code
4. Name
Relationship
Phone
Address

Address

Street Address Line 2

City
Zip Code
Signature of Parent/Guardian *

Clear
Date *

Month Day Year
Date
Should be Empty:

MEDICAL AND/OR EMERGENCY RELEASE:

PERMISSION TO ADMINISTER MEDICATION: