Spruce Tree Montessori Student Medical Profile Form 2023

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Spruce Tree Montessori Student Medical Profile Form 2023 - 24, Child 1

Student Name(s) *

Date of Birth *

Name of Child Family Physician *

Physician's Clinic and/or Address

Physician's Phone Number

Allergies

Yes

Clear selection

If yes, please list food and/or items identified as or suspected of causing the allergy.

If your child is to be provided medication for the allergy, please provide detailed instructions listing medication name, dosage and usage guidelines.

Has your child had his / her eyes tested?

Yes

Clear selection

Result

Has your child had his / her hearing tested?

Yes

Clear selection

Result

Is your child receiving medical treatment or counseling/therapeutic support?

Yes

Clear selection

If yes, please share treatment and/or medication plan.

Other medical or psychological notes to share?

Emergency Medical Treatment Release

In the event that the above named child becomes severely ill or seriously injured while at school, school staff will contact parents and/or the emergency contact name on file. When immediate medical attention is required, staff reserve the right to call 911 or the child's doctor. Doctor advice will be followed and/or emergency medical treatment administered. If a child has an injury requiring immediate attention, but not life threatening, Sabrina Binkley, Head of School, reserves the right to transport the child to the emergency room at Fairbanks Memorial Hospital. Parents will be notified. Spruce Tree Montessori School staff are CPR/First Aid certified.

I give permission for Spruce Tree Montessori School staff to administer the following over-the-counter medications using sound discretion as necessary for minor medical attention my child may need while at school. A medical attention report will be provided to parents via Montessori Compass.

Children's Tylenol

Children's Ibuprofen

Children's Benedryl

None

Other, parent provided (allergy, asthma, etc.)

Immunization Records: A copy of current immunization records is required to attend STMS. *

Please check this box to ensure understanding of this policy.

Required

Please check box beside the statement.

I certify that the information provide on this form is accurate and true.

Parent / Guardian Signature

Date

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms