Sturgis Charter Public School-West Emergency Medical Form For New Students
Please complete this emergency medical form for your child entering Sturgis West in one setting as you can not edit or change the information after you submit the form. If you need to make changes after you have submitted the form, please contact the school nurse. Please be assured that your responses will only be seen by the school nurse, are password protected, and will only be shared with school staff by the school nurse on a need to know basis (only when they will be providing direct supervision to your child).
Email address *
Student's First Name: *
Your answer
Student's Last Name: *
Your answer
Student's Date of Birth: *
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My child is in: *
Date of Entrance (the day your child did or will begin to attend Sturgis): *
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Previous School: *
Your answer
Parent/Guardian Name or Names: *
Your answer
Parent/Guardian Address: *
Your answer
With whom does the student live? *
Your answer
Student's Primary Care Physician:
Name *
Your answer
Phone Number *
Your answer
Student's Dentist:
Name: *
Your answer
Telephone: *
Your answer
Date of Student's Last Physical Exam: *
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Date of Student's Last Dental Visit: *
Your answer
Insurance Information:
This is only in case of an emergency and your child needs emergency medical attention. If your child currently does not have health insurance, please write N/A.
Insurance Company: *
Your answer
Policy Holder: *
Your answer
Policy Number (the number found on your child's health insurance card): *
Your answer
Health History
List of allergies (if your child does not have any allergies please write no known allergies): *
Your answer
What medications if any does he/she take regularly? If he/she will need medication during the school day please contact the school nurse as soon as possible. For safety reasons, no student is allowed to carry ANY medication, including over the counter medications, with the exception of an EpiPen or an inhaler, unless approved by the school nurse. *
Your answer
Has your child sustained any recent injuries requiring physician’s treatment? If so please explain, if not write N/A: *
Your answer
Has he/she had any recent hospital visits? If so please explain, if not write N/A: *
Your answer
Has he/she ever had a concussion? *
If so, what was the approximate date of the concussion?
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Does he/she have a history of mental health issues (anxiety, depression, bi-polar disorder etc.)? *
If yes, please indicate the condition below.
Your answer
Has he/she been hospitalized for mental health concerns? *
Is he/she currently receiving counseling services, or has he/she in the past year? *
If yes, what is the name of the counselor or mental health provider office?
Your answer
Does he/she seem to or has within the past year...please check all that apply: *
Required
Has he/she experienced any major changes in family life this past year (i.e. moving, divorce, loss of a close friend/relative, close friend/relative with serious illness, birth or adoption of a sibling or close family member,marriage of a parent)? *
If yes, please describe the circumstance.
Your answer
Please check any health conditions/concerns: *
Required
Does he/she wear glasses/contacts? *
Any vision or hearing concerns (can be diagnosed conditions or concerns you have may have as a parent)? *
If yes, please describe the vision or hearing concern.
Your answer
Does he/she have any present limitations (physical or academic) requiring program accomodations or restrictions (on crutches, uses walker, on a 504/IEP plan etc.)? *
If yes, please describe.
Your answer
Are any of his/her close family members in the military?
If yes, what is the relationship between the student and the military member?
Your answer
Anything else that was not mentioned above that you would like the school nurse to know? If not, please write No. *
Your answer
Non-Prescription Medication Consent:
The school nurse may assess and administer up to seven doses of the following over the counter medications to my child during the school year; Tylenol (acetaminophen) 325 mg-650 mg (1-2 tablets) every 4-6 hours, Motrin (Advil/ibuprofen) 200 mg-400 mg (1-2 tablets) every 6-8 hours, Cough drops 1-2 as needed, and Tums (calcium carbonate) 500-1000 mg (1-2 tablets) as needed.

I understand I will be notified if my child exceeds the seven dose limit and asked to sign and return the Non-Prescription Medication Consent and Order form to the school nurse. The school nurse will then forward the form to my child’s physician to obtain a medication order for the medications listed above.

*
Required
I give my consent for medication to be administered to my child under the following conditions...
Your answer
Emergency Contacts:
Please list someone other than yourself to be called in case of an emergency and the school is unable to reach you. Type in the text box below the person's name, relationship to your child, and phone number with area code.
Emergency Contact 1 *
Your answer
Emergency Contact 2 *
Your answer
Parental Releases:
Please read the following statements:

1. By providing my digital signature below I agree that the above information has been completed to the best of my ability.

2. By providing my digital signature below I agree that although my child’s health information is confidential, it may be shared on a need to know basis with school staff including substitute nurses and my child's teacher. A copy of this information may be given to a school staff member accompanying my child on a field trip or school outing. A copy of this information may be given to EMS in the event of an emergency.

3. By providing my digital signature below I acknowledge that I have read and understand both the medication and physical exam policy of Sturgis Charter Public School, which can be found on the school website to the right side of the page by clicking health offices under the department header at the top of the page.

4. By providing my digital signature below I understand that in case of illness or injury to my child, the school will make every effort to notify me. If I can not be reached, the school will notify the emergency contacts listed above. In the event that emergency medical care is necessary and I cannot be reached, I grant full power to Sturgis Charter Public School to contact emergency medical services and/or arrange transportation to the nearest medical facility for treatment and sign releases as required by the medical facility to obtain any medical or surgical treatment in the judgment of medical authorities at the facility.

Signature
Parent/Guardian, please type your full name and the date below. This will serve as your digital signature. *
Your answer
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