MJHS School Health Information

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

Student’s Information: _____________________________________________________________
                                        Last  Name                   First Name            MI        DOB             Grade

Address:____________________________________________First Block Teacher: ___________

Contact Information:

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.
_________________________________________________________________________________
(NOTE: An additional form signed by a physician is required for food allergies, please see cafeteria manager for this.)

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. List doctor’s name and phone number, and hospital preference in case of emergency.
__________________________________________________________________________________

6. Does your student have health insurance? Yes No If yes, please list.
__________________________________________________________________________________
Health Insurance Name                                                          ID#                                       Group #

7. 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

Parent/Guardian Signature _____________________________ Date_____________
Parents Signature gives Wilson County Schools permision to disclose and receive medical information on this student.
This form must be signed and turned in to your school nurse .