Greenville Technical Charter High School s1

Greenville Technical Charter High School 2015/2016 Health Form

Student’s Name ___________________Year of Graduation________Birth Date____________

Street Address _________________________________________________________________

Please indicate any health conditions that require treatments, procedures, medications or health monitoring for you student during the school day

_______________________________________________________________________________________

Mother/Guardian ________________Work Phone_____________Cell Phone__________Home Phone__________

Father/Guardian_________________Work Phone____________ Cell Phone________ Home Phone___________

Emergency Contacts: Please list two contacts that will be called ONLY if you cannot be reached in an emergency.

Name_________________________Relationship______________________Phone_____________________

The principal and/or health room attendant may share health information with individuals who have responsibilities for my child. I authorize school officials to contact the person named on this form and authorize the named physician to render to my child whatever emergency treatment deemed necessary. If the parent, or other persons named above, cannot be reached, school officials may take whatever action they deem necessary for the health of my child. I will not hold the School District of Greenville County and GTCHS responsible for the emergency care and/or transportation of my child. I will keep the school informed of any changes on this form.

Signature of Parent/Guardian___________________________________________Date______________

Please indicate below what if any conditions we should be aware of with your child

Asthma _______________ Medication_______________ Inhaler ________________

Allergies ______________ Medication_______________ EPIPEN _______________

Epilepsy ______________ Heart Condition ___________Severe Headaches ______

Kidney Disorder ________ Diabetes ______________

Hearing Loss __________Vision Loss ______________ Speech Defects __________

Migraines _____________Medication ______________________________________

ADD/ADHD____________ Medication______________________________________

Birth Defects or Deformities ______________________________________________

Emotional Problems____________________________________________________

Is your child under the care of a physician at the present?______________________

What medications does your child take daily? _______________________________

Year of last Tetanus booster (Tdap) _____________________________________

Students may not carry any medications on their person.

Not Advil, Tylenol, or any over the counter meds.

Prescription medications, epipens, inhalers, diabetic supplies etc., may not be on their persons without prior approval and the appropriate paperwork as per Greenville County Schools. The health room will dispense ibuprofen (advil) or acetaminophen (tylenol) to students with an “over the counter” form on file. All forms may be found at www.gtchs.org or by emailing or request by

phone 250-8962.