Consent for School Health Services

Consent for School Health Services - Phoenix Academy

Clark County Public Schools 09.224 AP.21
Please give child’s complete legal name:

Student's First NameMiddle InitialLast Name
Date of Birth:*

MonthDayYear
Grade:*
Student’s Medical History
**Please check if your child has any of the following:

AsthmaFrequent Throat InfectionsADHD/ADDDiabetesFrequent Ear InfectionsEmotional IllnessSeizuresEar TubesOrthopedic ProblemsAllergies (list below)Vision ProblemsHearing ProblemsBowel/Bladder ConditionHeart Condition (explain below)Lung ConditionOther Medical Conditions or History:
Allergies:
List all allergies
explanation of Heart Condition:
**Checkmark Any of the Following Medications that Your Child Requires:

Glucagon (diabetes)Epi-Pen (allergy)Diastat (seizures)Rescue Inhaler (asthma)
Medications taken on a regular basis:
Student’s Health Care Provider:
Dentist:
Other Special Health Care Providers:
I authorize the school health clinic to release and/or communicate any medical/dental/mental health information about my child to his/her healthcare providers. I also understand that the information obtained for the school physical including immunization information will be released to my child’s school. I understand that my child may be referred to mental health services during school hours as needed. In case of an emergency, I understand that my child may be taken to the nearest emergency room.
Signature:*

Clear
(Parent/Legal Guardian)
Date:*

MonthDayYear
(Expires 1 year from date signed)
Review/Revised:6/21/2016
Should be Empty:

Consent for School Health Services - Phoenix Academy

Student’s Medical History