MJHS School Health Information

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

 

Student’s name:  ______________________________________________________

              Last                               First                        MI

 

____
DOB

 

_____

Grade

 

 

____________________________________________________


____________
Teacher

 

Address

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.
(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. 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