Verification Of Student Admission Information (For Student Residing With Parent Or Guardian)/proof Of Residency Form Page 11
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132015-2016
Red Oak Independent School District
Health Services
Student ID Number:
Grade:
Teacher:
Car Rider:
Bus Rider:
Walk Home:
Day Care:
Car Driver (high school students):
Language Spoken at Home:
Student:
Birth Date:
Last
First
Middle
Address:
Mother/Guardian:
Primary Phone:
Cell Phone:
Work Phone:
Email:
Father/Guardian:
Primary Phone:
Cell Phone:
Work Phone:
Email:
Other Children at Red Oak I.S.D. (name & school):
Emergency Contact (other than parents):
Relation to Student:
Phone:
**********It is important that we are able to contact someone if your child is sick or injured.***********
****Hospital Preference:
2
Choice:
nd
(If your child needs immediate medical care)
I hereby authorize the Superintendent of Red Oak ISD or a designated representative to secure any and all emergency medical care and treatment
for the above named student for acute illness suffered or injury sustained while at school or participating in school-related activities. I prefer that
emergency treatment be secured at the above named facilities. The district may use another licensed hospital or medical facility if necessary.
I understand that cost of services provide by ambulance, private physician, hospital or dentist remains the responsibility of the parent of guardian and
will not be assumed by the district or any of its officers or employees.
Parent Signature______________________________________________________________________________________________
Does Student have: (Please Circle/Answer)
Allergies
Yes
No
Severe
Yes
No
If Yes:
Pollen?
Drugs?
Foods?
Insects?
Other: (Explain)
Has emergency care been needed in the past for an allergic reaction?
Yes
No
If YES: Hospitalization
Medication Only
Swelling at site
Student will have________will not have________an Epipen or medication for the allergic reaction at school.
Sign here_____________________________________________________
Asthma
Yes
No
Triggered by:
Treat with:
Student will have_____ will not have________asthma medication at school.
Sign here_____________________________________________
Diabetes
Yes
No
Controlled by: Insulin:
Diet
Seizures
Yes
No
Any restrictions?
Heart Condition
Yes
No
Any restrictions?
Bone/Joint Disorder
Yes
No
Any restrictions?
Frequent Headaches
Yes
No
Vision/Hearing Problem
Yes
No
Glasses
Contacts
Hearing Aids
Emotional Disorder
Yes
No
List any other serious illness or conditions not mentioned above:
Daily Medications
Yes
No
At home:
At school:
Name of medication:
Reason for medication:
I AGREE THAT THE TEACHERS & PERTINENT PERSONNEL BE ALLOWED TO KNOW OF THE ABOVE INFORMATION AND I HAVE READ
THE ROISD MEDICATION GUIDELINES.
Parent/Guardian Signature:
Date:
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