Manning Community School Health Record Update

IKM-MANNING COMMUNITY SCHOOL HEALTH RECORD UPDATE

2016/2017

In order to bring the individual school health records up to date, this form should be filled out and returned as soon as possible.

Name Birthdate Grade

Parent(s)/Guardian Home Phone Address Town Zip

Father's employer Work Phone Cell Phone

Mother's employer Work Phone Cell Phone

Email Address______

In case of illness, accident or other emergency and you cannot be reached, who shall we call that can PICK UP your child?

#1. Name Home Phone Work/Cell Phone

#2. Name _ Home Phone Work/Cell Phone _

Name of Doctor Phone Name of Dentist Phone Health Insurance Coverage: YES ______NO

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Does your child take any medications/treatments/procedures regularly? YES NO IF YES, please list and explain condition that is taking it for:

Will your child take this medication during school hours? YES NO IF YES, a School Administered Medicine Record must filled out. The medicine must also be in its original labeled container.

Does your child have allergies? YES NO IF YES, please list (including medicines, food, bee stings, latex, environmental or other):

How does your child react to this allergy? (If allergy is severe, an emergency health plan will need to be filled out).

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Please follow the medication guidelines, as all medications other than those you authorize below require written parental authorization. This includes any over-the-counter or prescription medication that your child needs to take during school hours. Please send it in the original bottle. If your child requires frequent administration of the meds below, please send them their own personal supply to be kept in the health office.

Do you give your permission for the following to be given to your child while at school?

Non-aspirin acetaminophen (Generic Tylenol) YES NO

Cough Drops (Generic Halls) YES NO

Skin ointments or analgesics/Eye drops YES NO Exception of:

(including but not limited to: triple antibiotic ointment, First Aid Cream, peroxide, Caladryl, calamine, burn spray, sunblock, insect repellant, Refresh or saline eye drops)

Vision screen, Hearing screen, Dental screen_____ YES _____ NO Exception of: ______

CHILD HISTORY:

Please list any illness, injuries or surgeries in the last year, and any chronic health conditions (such as asthma, ADHD, diabetes, migraines, skin disorders, etc.):

If your child has asthma, an Asthma Action Plan will need to be filled out.

Anything that happened to your child this summer you feel we should be aware of (i.e. death of family member, divorce, illness)?

Last dental exam Braces: Y/N Last professional vision exam Glasses/Contacts: Y/N

Has your child received any immunizations (tetanus or Tdap, Menactra, Gardasil, etc.) in the last year? If yes- what vaccine and dates:

Please remember our absence policy by calling the school each morning that your child is absent. If no call is received, we will attempt to call you to find out the reason for the absence. In an emergency situation, we will always attempt to contact the parent or guardian so they will be present for treatment. There are times, however, when other responsibilities necessitate absence from the area and could delay emergency care of minor children since parental consent must be given for that care. We need your permission for the staff of IKM-Manning Community Schools to utilize the services of the nearest emergency treatment center, should such an emergency arise. Your signature on this form authorizes the school to utilize the necessary emergency services when you cannot be reached. Your signature also authorizes that you assume financial responsibility for the child's medical care. This information may be shared with appropriate school personnel as needed to meet the child's health and safety needs.

Signature of Parent/Guardian Date