2020-2021 GLR Student Health Registration Student Name First Last Date of Birth MM slash DD slash YYYY Grade Gender When child is ill or injured, please list which parent/guardian the school should notify first. Please list in preferred order of contact.#1) Parent/Guardian Name First Last #1) Parent/Guardian Relationship #1) Parent/Guardian Cell Phone#1) Parent/Guardian Work Phone#2) Parent/Guardian Name First Last #2) Parent/Guardian Relationship #2) Parent/Guardian Cell Phone#2) Parent/Guardian Work PhoneIn case parent can’t be reached, please contact the individual below: This person has agreed to assume this responsibility and is local. #3) Contact Name First Last #3) Contact Relationship #3) Contact Cell Phone#3) Contact Work PhoneChild's Doctor First Last PhonePreferred Hospital Child's Dentist First Last PhoneOrthodontist Type of Health Insurance Private Title 19/Medicaid Hawk-I No Health insurance HEALTH CONCERNSMark the box if your child has a history of the following conditions. Mark additional information as needed. Additional forms may need to be completed by your physician (marked with *). Forms available on school website. Asthma or Reactive Airway Disease Yes No Asthma or Reactive Airway Disease Yes No Triggers Exercise Colds/Allergies Animals Smoke Weather Food Dust/Air Other Will the inhaler ever be needed at school? No Yes -- Asthma Action Plan* Will the student carry their own inhaler? No Yes -- Authorization to Carry/Self-Administer* Diabetes Type 1 Type 2 No Does the student use insulin? No Yes -- Diabetic Medical Management Plan* Does the student have glucagon? No Yes If YES...does the student need glucagon at school? No Office Backpack Locker If checked locker, what's the student's locker #? Seizure Disorder Yes -- Seizure Action Plan* No Does the student have rescue meds Yes No If YES...does the student need rescue meds at school? No Office Backpack Locker If checked locker, what's the student's locker #? Allergies [Food, Insect, Seasonal, Medication] Yes No Is the student at risk for anaphylaxis at school? Yes -- Allergy & Anaphylaxis Emergency Plan* No Will the student need a lunch accommodation? Yes -- Diet Modification Form* No Does the student have an EpiPen? Yes No If YES...does the student need an EpiPen at school? No Office Backpack Locker If checked locker, what's the student's locker #? List allergies below: Peanut Tree Nut Eggs Milk Fish/Shellfish Soybean Gluten Insects Seasonal Allergies Other List "other" allergiesList medications for allergiesHeart Condition/Murmur/Disease/Surgery Yes No If Yes, please explain:Activity Restrictions (ongoing) Yes No Doctor’s note required for explanation*If Yes, please explain:ADD / ADHD Yes No Emotional and/or Behavioral Diagnoses Yes No Anxiety Yes No Depression Yes No List other emotional and/or behavioral diagnosesIf have any emotional and/or behavioral diagnoses, does it require medication? Yes No List medication towards the end of the formHeadaches / Migraines Yes No If Yes, please explainBowel/Bladder Concerns or Incontinence Yes No If Yes, please explainAssistive Equipment No Glasses/Contacts Hearing Aids Wheelchair Other List other assistive equipmentHistory of Concussion / Head Injury Yes No If Yes, please explainOther medical history or current medical/developmental concerns that could affect child’s educationMedicationsList ALL medications taken regularly at home or at school. Please specify frequency and reason for use.Medication | Dose | Time(s) Taken | Frequency | School / Home Reason for use:Permission... I give permission to the school to administer over-the-counter medications (such as but not limited to acetaminophen, ibuprofen, antibiotic ointment or cough drops) to my child if supply is available. Medication will only be given per label indication and dosed according to age. I do NOT give permission to the school to administer any medications the school has available. Consent* I understand that any medication sent from home to be taken at school needs to be in the original labeled container and a Medication Authorization Form must be completed in order for it to be given. I understand that students may not carry any medications. I give permission to the school to contact my child’s doctor/dentist to confirm appointments and authorize medications/plans of care as necessary. If an emergency should arise, I agree to assume full financial responsibility for my child’s medical care. I understand it is my responsibility to update any of the above information as needed. I understand this information is confidential but may be shared with appropriate school personnel when necessary for the child’s safety or education. Signature*CAPTCHA
