MJHS School Health Information

This information is essential for prompt and efficient care of each student.

Student’s name: _________________________________________ Last First MI							______ DOB			_____ Grade
_______________________________________________					_______________			__________
Address					School			Teacher
Mother/Guardian Name				Father/Guardian Name
Mother/Guardian home# work# cell#
Father/Guardian home# work# cell#
Mother’s Email				Father’s Email
1. List any medical conditions that is presently being monitored by a physician ___________________ ______________________________________________________________________________ ______________________________________________________________________________
2. List allergies (food, medicine, or seasonal) and type of reaction experienced. __________________ ______________________________________________________________________________ ______________________________________________________________________________
3. List current medications taken at home or school with the dosage and time.____________________ ______________________________________________________________________________ ______________________________________________________________________________
Please note that medication to be given at school requires a form signed by the parent/guardian and/or physician and must be brought to school by the parent/guardian in proper container. See student agenda for more details.
4. List surgeries and hospitalizations including dates ____________________________________ ____________________________________________________________________________ ____________________________________________________________________________
5. Date of Last Tetanus Shot:
6. List doctor’s name and phone number, and hospital preference in case of emergency.
Doctor’s Name	Phone					Hospital
Dentist’s Name	Phone
7. Does your student have health insurance? Yes No If yes, please list.
Health Insurance Name			ID#						Group #
8. My child may be released to the following persons in case of an emergency or major disaster:
Name		Phone Cell
Name		Phone Cell
Name		Phone Cell
Name		Phone Cell
Name		Phone Cell
Out of State Contact

Parent/Guardian signature _____________________________ Date_______

This form must be signed and turned in to your school nurse