School Nurse Screening and Emergency Contact
Health screening and observation of students in K-12 are responsibilities charged to teachers and school nurses. Please complete the following information regarding your student.
Student Last Name *
Student First Name *
Student ID Number (Lunch Number) *
Bus Number *
Student Date of Birth *
Grade Level in 2020-2021 *
Parent/Guardian First and Last Name *
Parent/Guardian Telephone Number *
Parent/Guardian Alternate Telephone Number
Parent/Guardian Email Address *
It is important that the school is aware of any special health problems your child has. Please check all conditions below: *
Please explain any health conditions you selected in the question above.
Does your child require medication during school hours? *
If your child needs medication during school hours please list it below
If your student will require an emergency action plan for any condition selected above, please describe below.
If your child has asthma, will they be carrying an inhaler during school:
Clear selection
If your child has diabetes, will they be carrying an insulin pen, insulin pump, glucagon, or none of these:
Clear selection
If your child has seizures, what was the date of the last one? Will they be carrying Diastat or any other anti-seizure medication?
If your child has an allergy, will they be carrying an EpiPen during school:
Clear selection
Has your child had a head injury / concussion in the last year? If so, please list the date and details below:
Are there any other health conditions or medications from home we should be aware of?
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