Student Health Information Card '20-'21
Please answer all questions.
Sign in to Google to save your progress. Learn more
Student Name
Gender
Clear selection
Grade
Date of Birth
MM
/
DD
/
YYYY
Medicaid or AR Kids #
Private Insurance
Clear selection
Address
Home Phone Number
Mother/Guardian Name(s)
Mother/Guardian Cell Phone Number
Father/Guardian Name(s)
Father/Guardian Cell Phone Number
Please fill out up to 3 Authorized Emergency Contacts:
Authorized Emergency Contact
Phone Number
Relationship to Student
Authorized Emergency Contact
Phone Number
Relationship to Student
Authorized Emergency contact
Phone Number
Relationship to Student
Physican's Name
Physician's Phone Number
Hospital of Choice
Does your child ride a bus
Clear selection
Does student have a current diagnosis of any of the following? Check all that apply
Does the student have a current allergy to a medication? If so, please list
Does the student have a severe or life threatening allergy to any Foods, Latex or Stings? If so, please describe
Does the student have an EpiPen prescribed for severe allergies?
Clear selection
Is your child taking any medications?
Clear selection
If so, Please list medications:
Any other health issues you would like the nurse to be aware of?
Do you authorize the use of the following over the counter medications. Check for 'Yes'
I acknowledge that the Searcy County School District, the Board of Directors and School Employees shall be immune from civil liability for damages resulting from the administration of medications in accordance with this consent.
I will notify the school of any change in address, phone number, emergency contact or my child's health status. I understand the above information may be released to appropriate school district employees and emergency personnel in order to facilitate health care for my child. I also understand that in the event of an emergency, EMS will treat and transport my child to the nearest hospital. The hospital and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child.
In compliance with the Family Education and Privacy Act (FERPA) (20U.S.C. & 1232g; 34 CFR Part 99), I give my permission for my child's personally identifiable information/student education records to be disclosed to ISEP for the purpose of billing Medicaid and/or private insurance.
In compliance with the Family Education Right to Privacy Act (FERPA) (20U.S.C. & 1232g; 34 CFR Part 99), I give my permission for my child to participate in the School Immunization Clinic. I understand the appropriate Arkansas Department of Health consent forms will be provided for my consideration prior to the clinic.
Please Sign
Please Date
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Searcy County School District. Report Abuse
Google Forms