Health Informational Card (NS)(6)

Health Informational Card (NS)(6)
I've already done this form....
Student Name*

First NameMiddle NameLast Name
*

MaleFemale
Student date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade*

K123456789101112
Parent Email*
Guardian Name*

First NameLast Name
Guardian Cell Phone Number*
Format: (000) 000-0000.
Guardian Work PHONE NUMBER*
Format: (000) 000-0000.
Emergency contact (other than above)*
Date of last physical exam?*

MonthDayYear
Date
STUDENT HEALTH INFORMATION

If the following sections don't apply to the student, please select the "None" option or type "None" in the text boxes provided.
Medication: Please list all -prescription, over-the-counter, herbal. If do not take any medications, please mark NA. *
Will medication be needed at school?*

YesNo
If yes, list medication and when needed.
**No medication can be given at school without a doctor's order. Please contact the school nurse or school office for appropriate forms.**

School District Office Phone: 719-384-8103
Allergies:*

Bees/InsectsLatexNutsMedicationFoodNone
Please Describe
What medication does student require for treatment of this allergy?

EpiPenBenadrylNoneOther
Health concerns:*
**If you checked any of the above health concerns, please list any medications, treatments, therapies, activity restrictions, and/or medical equipment that will be need at the school:
**Have there been any significant changes in your child's health over the last year? Explain:*
Illness/Hospitalizations/Accidents/Injuries: Please list with approximate dates:*
Health care providers Name:*
Phone Number*
Format: (000) 000-0000.
Dentist:*
Phone Number*
Format: (000) 000-0000.
Please click the link and read the information for the next section of this form.

HEALTH INFORMATION
I have read and understood the Health Information, and can get more information about Swink School health policies in the Student Handbook, on the school website, or by contacting the school nurse. I give permission for the health information contained on this Health Information Card, to be shared with adults in the school setting who will be working with my child, on a need to know basis. It is the responsibility of the parent/guardian to notify the school nurse whenever there is any change in the student's health status or care.*

Yes
I give my child permission to use the sunscreen I have provided for them when it is needed during school activities.*

YesNo
I give permission for my child to be screened for hearing, vision, height and weight*

YesNo
If applicable allow the school nurse to pull immunizations to give to Otero College for enrollment in college classes.*

YesNoNA
Name of person filling this out.*

First NameLast Name
Signature of Parent/ Guardian completing this form*
office use only

Snap
Should be Empty: