Student Medical Information

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Please complete the following form for our nurse's records.

Email *

Student Name *

Date of Birth *

YYYY

Grade *

Gender *

Female

Male

State and County of Birth *

Homeroom Teacher *

Home Address *

Parent/Guardian #1 *

Phone Number 1 *

Additional Phone # 1

Parent/Guardian #2 *

Phone Number 2 *

Additional Phone # 2

Additional Emergency Contacts

(if parent cannot be reached)

a. Name

a. Relationship

a. Phone #

b. Name

b. Relationship

b. Phone #

c. Name

c Relationship

c. Phone #

Please list any siblings that also attend Wonderview School District:

The principal and/or school nurse may share health information with individuals who have responsibilities for my child. I authorize District officials to contact the person named on this form. If parents or other persons named above cannot be reached, the district officials may take whatever action they deem necessary for the health of my child. I will not hold WSD responsible for the emergency care and/or transportation of my child. I will keep the school informed of any changes of information on this form. By typing my name below I agree that it serves as my signature. *

Todays Date *

YYYY

Do you have Medicaid? *

Yes

If no, please list your insurance carrier:

Describe any important health-related information about your child:

List all prescription, over-the-counter and herbal medications you child takes regularly:

Does your child have any of the below listed conditions?

Allergies (food, insects, drugs, latex, etc...)

Allergies (seasonal)

Asthma or breathing problems

Attention Deficit / Hyperactivity Disorder

Behavioral Problems

Speech Problems

Developmental Problems

Hearing Problems of Deafness

Vision Problems

Heart Problems

Seizures

Other:

If yes to any of the above, please explain:

Please note that Tylenol, Ibuprofen, oral Benadryl, etc... is not kept in the office. If you want your child to take these medicines you may bring a bottle and leave it in the nurse's office. PLEASE NOTE: All medications (prescription or OTC) are required by law to be dropped off at the nurse's office by a parent/guardian. Please check any item that may NOT be used on your child: *

2nd Skin Sterile Squares

911 Relief

Adolf's Meat Tenderizer

Alcohol

Anbesol

Bactine

Baking Soda

Benadryl Cream

Benadryl Gel

Benzalkonium Antiseptic Wipes

Biofreeze

Burn Free

Burn Jel

Calagel

Campho-Phenique

Carmex

Chiggerex

Cortizone 10

Dental Wax

Gold Bond Body Powder

Jergens Lotion

Natural Care Huggies Baby Wipes

Neosporin

Peroxide

Purified Water Sterile Solution

Re-nu Contact Solution

Refresh Lubricant Eye Drops

Salt (water gargle)

Silver Solution

Solarcaine

Sting Relief

Tea Tree Oil

Tecnu

Tinactin

Vaporub

Vaseline

None of the Above

Required

I give the school nurse my permission to apply over the counter medicines to my child (with the exception of the above). My typed name below serves as my signature.

Family Physician *

Physician Phone # *

Dentist *

Dentist Phone # *

Send me a copy of my responses.

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