Sturgis Charter Public School-West Emergency Medical Form For New Students

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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 *

Student's First Name: *

Student's Last Name: *

Student's Date of Birth: *

YYYY

My child is in: *

9th grade

10th grade

Date of Entrance (the day your child did or will begin to attend Sturgis): *

YYYY

Previous School: *

Parent/Guardian Name or Names: *

Parent/Guardian Address: *

With whom does the student live? *

Student's Primary Care Physician:

Name *

Phone Number *

Student's Dentist:

Name: *

Telephone: *

Date of Student's Last Physical Exam: *

YYYY

Date of Student's Last Dental Visit: *

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: *

Policy Holder: *

Policy Number (the number found on your child's health insurance card): *

Please check here if you or your child does not currently have health insurance and you would like to speak with the school nurse for more information on attaining health insurance coverage.

Please check here if you or your child does not currently have dental insurance and you would like to speak with the school nurse for more information on attaining health insurance coverage.

Health History

List of allergies (if your child does not have any allergies please write no known allergies): *

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. *

Has your child sustained any recent injuries requiring physician’s treatment? If so please explain, if not write N/A: *

Has he/she had any recent hospital visits? If so please explain, if not write N/A: *

Has he/she ever had a concussion? *

Yes

If so, what was the approximate date of the concussion?

YYYY

Does he/she have a history of mental health issues (anxiety, depression, bi-polar disorder etc.)? *

Yes

If yes, please indicate the condition below.

Has he/she been hospitalized for mental health concerns? *

Yes

Is he/she currently receiving counseling services, or has he/she in the past year? *

Yes

If yes, what is the name of the counselor or mental health provider office?

Does he/she seem to or has within the past year...please check all that apply: *

Cry often

Get easily upset

Be angry often

Be Troubled/worried

Be Unhappy

None of the above

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)? *

Yes

If yes, please describe the circumstance.

Please check any health conditions/concerns: *

Asthma

ADD/ADHD

Cardiac Conditions

Chronic Strep Throat

Diabetes

Frequent Headaches

GI Problems

Lyme Disease

Mononucleosis

Painful Periods

Pneumonia

Seizure Disorder

Scoliosis

None of the above

Required

Does he/she wear glasses/contacts? *

Yes

Any vision or hearing concerns (can be diagnosed conditions or concerns you have may have as a parent)? *

Yes

If yes, please describe the vision or hearing concern.

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.)? *

Yes

If yes, please describe.

Are any of his/her close family members in the military?

Yes

Clear selection

If yes, what is the relationship between the student and the military member?

Anything else that was not mentioned above that you would like the school nurse to know? If not, please write No. *

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.

By checking here I give my consent for medication administration to my child and agree to all of the conditions listed above.

I do not give permission to the school nurse to administer medication to my child.

I give my consent for medication to be administered to my child under certain conditions (for example please give only Tylenol and not Motrin or may give all other medications except Tums etc.) Please indicate your conditions below.

Required

I give my consent for medication to be administered to my child under the following conditions...

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 *

Emergency Contact 2 *

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.

By clicking here I agree to the statements above.

Signature

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

Submit

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