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SPS Registration: Life Threatening Health Conditions
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Life Threatening Health Conditions
Last Name
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First Name
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Middle Name
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Date of Birth
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Parent/Guardian first & last name
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Home/Cell Phone
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Email
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Please describe your child’s current health condition below. It is important that you keep the school informed of any changes in health or medication that would affect your child at school. If your child needs to take medication at school, please notify the school office. My child has NONE of the health concerns listed below:
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Yes
No, my child has one or more health concerns listed below (see below)
Life Threatening Conditions: If anything is checked as LIFE THREATENING, notify your school’s nurse immediately and obtain LIFE THREATENING paperwork from school office. This is REQUIRED PER RCW 28A.210.320 for attendance at school. Please check all that apply:
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Allergy/Anaphylaxis REQUIRING an Epi-Pen/Adrenalin auto-injector prescription (example: food, insect stings)
Allergen(s) please list below
Asthma: ALL ASTHMA IS CONSIDERED LIFE THREATENING AND REQUIRES A PHYSICIAN’S ORDER AND EMERGENCY ACTION PLAN
Diabetes Type 1
Diabetes Type 2
Seizure Disorder: My student needs emergency medication for seizures. List name of medication below
Not Applicable
Other:
Required
Special Health Care Planning: My child has special health care needs such as: wheelchair, tube feedings, catheter, intravenous tubes, eating and swallowing concerns*, or other.
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Yes
No
Not Applicable
Other:
Health Conditions: Check any conditions that your child has:
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Behavioral/mental health
Blood Disorder
Bowel/bladder
Cancer
Depression/Anxiety
Digestive Disorder (requires LHP orders)
Hearing loss and/or wears hearing devices
Heart Problems
Medication/Drug Allergy
Neurological
Orthopedic
Respiratory problem
Skin
Not Applicable
Other:
Required
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