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NRHS Health Form
This form will be provided to the doctor or medical personnel to which your child is taken in the event of a medical emergency during a school sponsored trip/event. Please complete all the required sections as accurately as possible.
Student Name
Your answer
Grade
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Home Address
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Phone #
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Date of Birth
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DD
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EMERGENCY CONTACTS
Mother
Your answer
Home #
Your answer
Work #
Your answer
Cell #
Your answer
Father
Your answer
Home #
Your answer
Work #
Your answer
Cell #
Your answer
Other
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Home #
Your answer
Work #
Your answer
Cell #
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Family Doctor
Your answer
Phone #
Your answer
INSURANCE INFORMATION
Per NASD policy JHA, all student/athletes must have medical insurance to participate in school athletics. Please enter the required information. "ON FILE" is not a valid entry
Health Insurance Co.
Your answer
Policy Number
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ANNUAL HEALTH SCREENING
Medications
Your answer
Check if uses:
Allergic Reactions:
Medications
Your answer
Food
Your answer
Other
Your answer
Any ongoing health concerns?
Your answer
Any hospitalization or surgery in past year (please list).
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Any newly diagnosed medical conditions?
Your answer
Have you ever experienced chest pain, dizziness or fainting with exercise?
If yes, please explain
Your answer
Any problems with head, neck,back,arms or legs in the past year?
If yes, please explain
Your answer
Have you ever had a concussion?
If yes, please explain and tell approximately how long ago
Your answer
Do you have any missing organs(eye,kidney) or loss of function of an organ
If yes please explain
Your answer
Please list any other information you feel could be pertinent
Your answer
PLEASE READ CAREFULLY AND INITIAL
Treatment & Transportation
I, the parent,guardian authorize the school's representative to transport and authorize treatment for my child in the event of an emergency situation involving an accidental injury or illness, when a parent/guardian can not be reached. I agree that i will not hold this person liable while h/she is acting according to these directions.
Signature
Your answer
Contact Doctor/Dentist
I, the parent/guardian, understand that communication between the medical health provider and the school's health office is necessary for the purposes of sharing information regarding immunization records, physical exams, dosage, administration, and effectiveness of medication and I give my authorization for such communication to occur.
Signature
Your answer
Field Trip Medication Authorization
I, the parent/guardian, authorize the staff to give my child his/her medications and medical treatments on field trips. The nurse will give the medications and instruction to the staff member prior to the field trip.
Signature
Your answer
Over the counter Medication Authorization:
I, the parent/guardian, authorize the school nurse or other authorized personnel to treat minor injuries or illnesses with the following over the counter medications:
You may decline any of the following items by leaving them blank
Signature
Your answer
Medication Assistance
I, the parent/guardian, authorize the school nurse or other authorized personnel to assist my child in the taking of medications that are delivered directly to the nurse's office. The medication must be in the original container, with the pharmacy label on it. The label must contain the student's name, name of the medication, dose, time medication is to be given and the medical provider's name. Student's are not allowed to carry medication unless it is an inhaler or epipen for which a physicians order MUST be on file in the nurse's office.
Signature
Your answer
Athletic Health Screening
According to the NH Interscholastic Athletic association, students are not eligible for participation in interscholastic sports if they have not successfully passes a physical examination by a licensed medical provider at the beginning of their high school career. In addition, the Newfound Area School District will require an annual health screening from the parent/guardian stating that your child remains in good health.

I, the parent/guardian certify that my child is in good physical condition and is able to participate in interscholastic sports and/or any other school sponsored activities during the current school year.

Parent/Guardian Signature
Your answer
Date
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