Nurse Clinic Form

School:*

Grade:*

Name:*

First NameMiddle NameLast Name

Date of Birth:*

Date

Home Address:*

Parent or Guardian's Name:*

In case of emergency, please call:
Parent / Guardian 1 Name: Name
Relationship to student: Relationship
Contact Numbers: Home #Home #   Work #Work #   Cell # Cell #
Employer of Parent/Guardian 1:  Employer

Parent / Guardian 2 Name: Name
Relationship
Contact Numbers: Home # Home # Work # Work #  Cell #
Cell #
  Employer of Parent/Guardian 2: Employer

If a parent cannot be reached, I authorize Thomasville City Schools to call the person(s) listed below. I also authorize those listed to sign my child out of school.

Name: Name Relationship: Relatiohship Home# Home#Work# Work# Cell# Cell#
Name Relationship: Relatioship Home#Home#Work# Cell# Cell#
NameRelationshipHome#Work#Cell#
NameRelationshipHome#Work# Cell# Cell#

Please list brothers and sisters that are enrolled in the Thomasville City School System:

Name Grade: Grade School: School
NameGradeSchool
NameGrade School: School
NameGradeSchool

Asthma:

Does your child have Asthma?

YesNo

Will your child require an inhaler at at school?

YesNo

Will your child need to keep his/her inhaler with them at school?

YesNo

List the name(s) of your child's asthma medication(s):

List what may trigger an asthma attack in your child:

Allergies:

Please list any allergies you are aware of that your child may have:

Is your child allergic to certain foods? (If yes, click "Specify" and list foods.)

YesNoSpecify

Is your child allergic to medications? (If yes, click "Specify" and list medications.)

YesNoSpecify

Is your child allergic to bee stings?

YesNoSpecify

If so, what type of reaction usually occurs?

Will your child require keeping an Epi-pen at school for sever allergic reactions?

YesNo

General Health: (Answer YES or NO. If YES, please give details)

Family Doctor Name:

Phone Number

Please enter a valid phone number.

Seizures

YesNo

Kidney Problems

YesNo

Fainting Spells

YesNo

Nose Bleeds

YesNo

Diabetes

YesNo

Physical Impairments

YesNo

Heart Condition

YesNo

Sickle Cell Disease

YesNo

Explanation of any "YES" answers

Other conditions not listed:

Does your child require special seating in the classroom? Specify:

Does your child have any condition that would limit physical education (PE) activities? If so, please explain:

Students will receive general First AId, which may include a number of topical and some oral agents at the nurse's discretion: Acetaminophen for headaches/pain, Ibuprofen for pain and/or menstrual cramps, Antacids for stomach upset/indigestion, Orajel/Anbesol for minor tooth aches/pain, Antibiotic ointment for use on scrapes/cuts, Eye Drops for eye irritation, Antifungal cream for ringworm, Hydrocortisone cream for inflamed bug bites, Caladryl or Benadryl cream for itching bug bites/poison ivy, Benadryl for minor allergic reactions. Parents will not be contacted for minor First Aid treatment unless the nursing office receives a request in writing from the parent. It is vital that the school nurse be made aware of any sensitivity or previous allergic reaction to any medications. The parent is required to notify the school of any changes in medical history.

In case of serious illness/injury, the school will render first aid as prescribed by School Board Regulations while contacting the parent. If the situation is serious and a guardian cannot be found, the school will call 911 for an Emergency Medical Unit to transport to Archbold Memorial Hospital Emergency Room. Fees for transportation and medical services will be the responsibility of the parent/guardian.

I, Name* , give the School permission to call doctor for any medical information.

Signature

Date

THOMASVILLE CITY SCHOOLS CLINIC RECORD