Health Services Emergency Information form
STUDENT'S NAME:▁▁▁▁▁▁ SCHOOL YEAR:▁▁▁▁▁▁ GRADE:▁▁▁▁▁▁ HOME PHONE:▁▁▁▁▁▁
SCHOOL:▁▁▁▁▁▁ RETURNING STUDENT:▁▁▁▁ NEW:▁▁▁▁
PREVIOUS SCHOOL'S NAME & PHONE NUMBER (if in NY): ▁▁▁▁▁▁
DATE OF BIRTH:▁▁▁▁▁▁ MALE:▁▁▁▁ FEMALE:▁▁▁▁ HOME ADDRESS:▁▁▁▁▁▁
Please describe any new or ongoing HEALTH CONDITION that the School Nurse should be aware of to help your child while he/she is at school. Please include any ALLERGIES your child may have and the necessary treatment:▁▁▁▁▁▁▁▁▁▁
Please list any medication that your child is currently taking:▁▁▁▁▁▁▁▁▁▁
If your child requires any medication during school hours, please contact the School Nurse for the required permission forms. The medication must be brought to the School Nurse by the parent in the original prescription bottle with the pharmacy label.
Student's Health Care Provider:▁▁▁▁▁▁ Phone:▁▁▁▁▁▁
Mother's Name:▁▁▁▁ Cell Phone number:▁▁▁▁ Place of Employent During Day:▁▁▁▁ Phone number at Work:▁▁▁
Father's Name:▁▁▁▁ Cell Phone number:▁▁▁▁ Place of Employent During Day:▁▁▁▁ Phone number at Work:▁▁▁
If my child needs to be taken home becuase of a minor illness or injury and I cannot be reached, please call:
1. Name:▁▁▁▁▁▁ Relationship to Child:▁▁▁▁▁▁ Phone Number:▁▁▁▁▁▁
2. Name:▁▁▁▁▁▁ Relationship to Child:▁▁▁▁▁▁ Phone Number:▁▁▁▁▁▁
3. Name:▁▁▁▁▁▁ Relationship to Child:▁▁▁▁▁▁ Phone Number:▁▁▁▁▁▁
PERSONS SIGNING OUT STUDENTS MUST PROVIDE A VALID FORM OF PHOTO IDENTIFICATION.
I understand that this confidential information will be shared with the school personnel deemed appropriate by the health professional in my child's building. If my child has a serious illness or injury and parents or emergency numbers cannot be contacted, please have my child transported to the nearest emergency room by ambulance, accompanied by authorized school personnel, if necessary. I realize that the school district cannot assume responsibility for the payment of expenses incurred. I certify that all of the above information is correct.
Parent's/Guardian signature:▁▁▁▁▁▁ Date:▁▁▁▁▁▁
The Middletown School District asks parents to keep their child home from school if they show any signs of significant illness. If your child has had a fever (above 100.4 degrees F), he/she should not return to school until his/her temperature has been normal for at least 24 hours. Please have any child with a rash or eye inflammation checked by your health care provider to determine whether the condition is contagious and may require treatment. If your child has a significant injury, please inform the School Nurse so that necessary modifications can be made for your child's safety until his/her injury resolves.
THANK YOU FOR RETURNING THIS FORM TO YOUR CHILD'S SCHOOL NURSE AS SOON AS POSSIBLE!