Austintown Local School District
Emergency Medical (School Year 2015-16)
Student Information
For School Use Only:
Date of Birth:
Student Name:
Homeroom #____________
Gender:
Grade:
City/State:
Zip:
Address:
Parent/Guardian Information
Parent/Guardian Information
Name:
Name:
#1 Contact Cell:
#1 Contact Cell:
#2 Contact Home :
#2 Contact Home:
Relationship to Student:
Relationship to Student:
Mother / Stepmother / Guardian / Foster Mother (please circle)
Father / Stepfather / Guardian / Foster Father (please circle)
Is your address the same as student’s? __ Yes __ No
Is your address the same as student’s? __ Yes __ No
(If No, what is your current address)?
(If No, what is your current address)?
Current Address/Zip:
Current Address/Zip:
Residential Parent / Guardian Information (please answer Ques. A, B, & C)
Are the student’s parents/guardians (please X one):
B.
A.
Student lives with (please X one):
__ Married __ Divorced __ Separated __ Never Married __ Otherwise
__ Both Parents __Mother Only __Father Only __Other: ___________
living separately, please explain:
_______________________________
If Separated or Divorced, Custody Papers are Required for
C.
Who has legal custody for child(ren) (please X one):
Student File.
__ Both Parents __Mother Only __Father Only __Shared
__ Other: __________
For Joint-Custody, Please Provide Addresses of Both Parents.
Emergency/Alternate Contacts
In the event you are unable to reach me at the above numbers, you have my permission to contact the following alternates. They have my permission to receive health
care information regarding my child and can take them home during school hours if needed. ( Additional contact space provided on the back of form)
Contact 1 (Other than Parent/Guardian)
Contact 2 (Other than Parent/Guardian)
Name:
Relationship:
Best Contact Number:
Emergency Authorization
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by
named doctor below, or in the event the designated practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any
hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring
in the necessity for such surgery, are obtained prior to the performance of such surgery.
Consent given?
Yes (after reasonable attempts to contact parent/guardian)
PLEASE CIRCLE ONE
No (If no, please give instructions)
Consent Refusal Instructions:
Medical Contacts (if consent was given above, please enter contacts)
Doctor
Name:
Phone:
Dentist
Name:
Phone:
Hospital
Name:
Phone:
Branch ( if more than one location):
Medical Information (*Forms for each condition and medications administration forms are available from the school clinic) :
Please circle Yes or No
Will medication be
If yes, Name and
taken at school?
Dose
Inhaler: Yes or No
Asthma*:
Yes or No
Yes or No
Yes or No
Diabetes*:
Yes or No
Yes or No
Yes or No
Seizures*:
Explain:
Yes or No
Allergies*:
Yes or No
Explain:
Yes or No
Yes or No
Food Allergies*:
Explain:
Yes or No
Yes or No
Sting Allergies*:
Explain:
Yes or No
Yes or No
Heart Condition*:
Explain:
Yes or No
Yes or No
Other:
The Austintown Local School District Nurses (or other trained personnel) may administer acetaminophen (Tylenol) for pain during this school year,
1.
to the students with signed parental permission? This applies to Grades 4-12 only.
Yes or No (please circle one)
2.
The Austintown Local School District Nurses (or other trained personnel) may administer Benadryl for emergency reaction only, during this school
year, with signed parental permission?
Yes or No (please circle one)
rd
th
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3.
BMI Screening (Body Mass Index screening for Grades Kg, 3
, 5
& 9
only). Part of Healthy Choices for Healthy Children Act.
PLEASE
Do you consent to have this screening done?
Yes or No (please circle one)
ANSWER
Grade student attend the boys’ or girls’ puberty education program presented by a district Registered Nurse?
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4.
May your 5
QUES. 1-4
Yes or No (please circle one)
AND SIGN
Date:
Signature: