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:
| Mother/Guardian Name |
Father/Guardian Name |
| Work # Cell# |
Work # Cell# |
| Home# |
Home# |
| Email |
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.
_________________________________________________________________________________
(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 .
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