CONFIDENTIAL STUDENT HEALTH SERVICES EMERGENCY INFORMATION CARD
PLEASE PRINT: Student Record No: ______Today's Date: ______
Student’s Name: ______Grade: ______HR: ______
Last First Middle
Email Address______
Birth Date: ______Age: ______Bus No: ______
Address: ______City: ______State: PA Zip: ______
Home Phone (_____)______Cell Phone (_____)______Cell Phone (______)______
HEALTH INSURANCE: ______ID No. ______
Mother’s Name: ______Maiden Name ______
Employer: ______Work Phone (_____)______
Father’s Name: ______
Employer: ______Work Phone (_____)______
Names of Two Persons Who Will Assume Temporary Care of Your Child If You Cannot Be Reached. List the Relative or Friend You Would Like the School to Notify. Name Two Persons in the Local Area With Transportation In Order of
Preference.
1. Name ______Relationship ______
Address ______Phone No. (_____)______
2. Name ______Relationship ______
Address ______Phone No. (_____)______
List Known Medical Problems/Surgeries: ______
Allergies: _____ No _____Yes List Allergies: ______
Does you child need a prescription adrenalin autoinjector (Epi-Pen) in school? ______No ______Yes
Physician’s Name: ______Office Phone: ______
Dentist’s Name: ______Office Phone: ______
Hospital Where Student is to Be Taken in Case of an Emergency: ______
In case of a radioactive emergency during school hours and when instructed by public officials:
_____ Yes I DO want my child to be given potassium iodide tablet. My child does not have an allergy to iodide.
_____ No I DO NOT want my child to be given potassium iodide tablet
_____ My child has an allergy to iodide and should not be given potassium iodide. (Please check if applicable)
In Case of Accident or Serious Illness, I request the School to Contact Me. If the School is Unable to Reach Me, I Hereby Authorize the School to Call the Physician Indicated Below and to Follow Her/His Instructions. If it is Deemed Impossible to Contact the Physician, The School May Make Whatever Arrangements Seem Necessary. I Hereby Agree to Hold the South Side Area School District and its Representatives Harmless for Exercising its Judgment in Authorizing Such Medical Treatment.
If there are questions or concerns, please contact Elementary School Nurse, Mrs. Mzyk at 724-573-9581 Ext. 1104
Parent/ Guardian Signature:______Date: ______
PLEASE COMPLETE THE ANNUAL HEALTH HISTORY UPDATE ON THE OPPOSITE SIDE
ELEMENTARY HEALTH SERVICES CONFIDENTIAL ANNUAL HEALTH HISTORY UPDATE
NO MEDICATION WILL BE ADMINISTERED IN SCHOOL WITHOUT A WRITTEN PHYSICIAN PRESCRIPTION
Date ______Name ______HR ______
1. Has the child had strep in the past year? ____ No ___ Yes
2. Has the child had any difficulty with ears/hearing? ____ No ___ Yes
If yes, please explain ______
3. Does the child presently have tubes in the ear? ____ No ____ Yes
___ Left ___ Right ____ Both ____ None presently If yes, please explain ______
4. Has the child had any trouble with eyes/vision? ____ No ____ Yes
5. Does the child wear glasses? Month/Year glasses were prescribed ______No ____ Yes
6. Does your child have allergies or reaction to bee stings, any medicine or plants, or food? ____ No ____ Yes
For example, milk intolerance, allergy to chocolate, strawberries, peanuts or nuts.
If yes, please describe the specific allergen, reaction and what relieved the symptom(s)
______
7. Does the allergy require specific medication treatment? For example, ____ No ____ Yes
Epinephrine (Epi-Pen) autoinjector ordered by your doctor and to be kept
at school.
If yes describe medication and treatment ______
Please phone or visit the school nurse immediately.
Does your child require an epinephrine autoinjector in school? If yes, please provide the ____ No ____ Yes
autoinjector and written physician prescription indicating allergen with specific
instructions for use of epinephrine autoinjector.
8. Has the child had allergy testing/shots? If yes, Month ______Year ______No ____ Yes
9. Does your child take medication regularly at home? ____ No ____ Yes
If yes, please list ______
10. Has the child been diagnosed with asthma? If yes, Month ______Year ______No ____ Yes
11. Is your child currently taking any medication for asthma? ____ No ____ Yes
If yes, please list medications taken at home.
______
12. Does your child require asthma medication at school? ____ No ____ Yes
If yes, please list the medication ______
and provide the school nurse with the medication and written physician prescription.
Please phone or visit the school nurse immediately.
13. Does your child have a heart murmur or any activity restrictions during the school day? ____ No ____ Yes
If yes, please explain ______
14. Do you anticipate your child needing medication regularly? ____ No ___ Yes
If yes, please contact the school nurse the first day of school.
15. Has your child ever been hospitalized or had surgery ____ No ___ Yes
If yes, please explain ______
______
Date Parent/Guardian Signature
PLEASE COMPLETE THE EMERGENCY CARD ON THE OPPOSITE SIDE