Student Health Center Update of Information Form

School:*

Grade:*

Student Name:*

First Name Last Name

Date of Birth:*

Students Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Please enter a valid phone number of parent or guardian.

Emergency Contact Name:*

Emergency Contact Phone Number:*

Emergency Contact Relationship to Student:*

Student's Primary Care Doctor:*

Date of last Physical/Well Child Check:*

Student's Dentist:*

Medications (type/amount/times taken):*

Allergies/reactions:*

Medical conditions/injuries/hospitalizations:*

Any change in family medical history:*

Federal law requires that we notify you of the ways we may share health information. We are required to provide you with the Notice of Privacy Practices. The Notice of Privacy Practices is available in each of the Student Health Centers or you may request a printed copy from any Health Center staff. By signing below, you are ackowledging the following statements:

I have been offered a copy of the Notice of Privacy Practices.
I have read the enclosed information and I give permission for my child to receive services from the student health center from the date signed through the remainder of the school year.
I agree that the Student Health Center may share medical record information with my child's physican/dentist.
I agree for my child's insurance to be billed for services/treatment provided to my child in the Student Health Centers.
I consent for Student Health Center staff to communicate with school staff as needed regarding information pertinent to my child's health.

Signature*

Date*

Date