CVSD Registration: Life Threatening Health Conditions

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Email *

Student Last Name *

Student First Name *

Student Middle Name *

Date of Birth *

YYYY

Parent/Guardian first & last name *

Home/Cell Phone *

Parent/Guardian Email *

Please describe your child’s current health condition below. It is important that you keep the school informed of any changes in health or medication that would affect your child at school. If your child needs to take medication at school, please notify the school office. My child has NONE of the health concerns listed below:
*

Yes

No, my child has one or more health concerns listed below (see below)

Life Threatening Conditions: If anything is checked as LIFE THREATENING, notify your school’s nurse immediately and obtain LIFE THREATENING paperwork from school office. This is REQUIRED PER RCW 28A.210.320 for attendance at school. Please check all that apply:
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Allergy/Anaphylaxis REQUIRING an Epi-Pen/Adrenalin auto-injector prescription (example: food, insect stings)

Allergen(s) please list below

Asthma: ALL ASTHMA IS CONSIDERED LIFE THREATENING AND REQUIRES A PHYSICIAN’S ORDER AND EMERGENCY ACTION PLAN

Diabetes Type 1

Diabetes Type 2

Seizure Disorder: My student needs emergency medication for seizures. List name of medication below

Not Applicable

Other…

Required

Special Health Care Planning: My child has special health care needs such as: wheelchair, tube feedings, catheter, intravenous tubes, eating and swallowing concerns*, or other.
*

Yes

Not Applicable

Other:

Health Conditions: Check any conditions that your child has:
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Behavioral/mental health

Blood Disorder

Bowel/bladder

Cancer

Depression/Anxiety

Digestive Disorder (requires LHP orders)

Hearing loss and/or wears hearing devices

Heart Problems

Medication/Drug Allergy

Neurological

Orthopedic

Respiratory problem

Skin

Not Applicable

Other:

Required

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