Emergency Contact Information & Health History
Please complete one of these forms for each new student that you wish to enroll at Northwest Elementary School for the 2021-2022 academic school year. **
If you would like to speak directly to the School Nurse to further discuss any medical needs, you can:
1) Email Mary Stiverson (
2) Call 740-259-2250, choose option 3 or extension 3306, leave a message, and your call will be promptly returned.
**The information collected through this form will only be sent to those individuals authorized by the district to access confidential information. You will still be required to sign a physical copy of an Emergency Medical Authorization form to "grant consent for" or "refuse to consent for" emergency medical treatment to be sought for your child in the event of an emergency.
I am completing this survey for a child entering _____________ for the 2021-22 Academic School Year
Child's First Name
Child's Last Name
Child's Date of Birth
Gender of Student
Student's Complete Address and P.O. Box if applicable
If your child is transferring to our school, please list the Name, City and State of the last school attended. If the child is new to Kindergarten or Preschool, just leave blank.
Legal Parent(s)/Guardian(s) Names
Home Telephone number
Relationship of Legal Parent(s)/Guardian(s) to child
Foster Parent (child in custody of Children Services)
Temporary Custodian through Juvenile Court Order
Legal Custodian through Juvenile Court Order
Biological Father's First and Last Name, cell number and/or best daytime phone number.
Biological Mother's First and Last Name, cell number and/or best daytime phone number.
List any other adults to whom your child may be released, relationship to the child and telephone numbers.
Name of child's primary care physician
Name of child's dentist
Preferred local hospital
Southern Ohio Medical Center
King's Daughter's Medical Center
Name of child's medical specialist - if applicable
Please list any allergies, heart problems, diabetes, cancer or other serious health conditions of the child's BIOLOGICAL FATHER.
Please list any allergies, heart problems, diabetes, cancer or other serious health conditions of the child's BIOLOGICAL MOTHER.
Did the mother have any unusual physical or emotional illness during this pregnancy? If yes, please explain.
Was the infant born full term? If no, how many weeks was the pregnancy?
Did the infant have any sickness or problems? If yes, please explain.
How does the child's development compare to other children, such as a brother/sister or playmates?
About the Same
Please check all the conditions below for which your child receives regular medical/health care for the following conditions:
My child has NO medical conditions for which he/she received regular medical care
Ear problem/hearing difficulty
Sickle Cell Anemia
Traumatic Brain Injury
Please explain any conditions above or any reasons for hospitalizations:
Please indicate any allergies your child may have:
No known allergies
If any allergies were indicated above, explain the reaction the child may have and any school restrictions or recommended actions associated with each allergy.
Please list any prescription and over the counter medications that your child takes on a regular basis. Include the name of the medication, dose, the time of the dose and the reason the medication is given:
Do any of your child's health and/or medical conditions require school restrictions, modifications, and/or intervention? If yes, please explain.
Does your child require any special procedures and/or treatments for their health conditions? If yes, please explain.
Please provide any other information about your child's health or development that you think would be helpful for the school to know.
Name of person submitting this form and relationship to the child.
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