Health services form
HAWAII BAPTIST ACADEMY
2012-2013 Health Services Form
STUDENT’S NAME:______________________________________________ GRADE:______
Last First M.I.
MEDICAL INFORMATION
Does your child have any health conditions such as asthma, diabetes, seizure disorder,
ADHD, or any other health problem that the nurse should be aware of?
______________________________________________________________
______________________________________________________________
Does your child take any medication daily or as needed? Please list the names of the
physician prescribed medications, the dosages and the time medication is taken.
______________________________________________________________
______________________________________________________________
______________________________________________________________
List al al ergies:
______________________________________________________________________
______________________________________________________________________
***Is your child prescribed an EpiPen for a severe al ergic reaction? _______________
Physician’s Name: __________________________ Physician’s Phone: ___________
Medical Insurance: ____________________ Policy Number: _____________________
Subscriber’s Name: _____________________________________________________
PARENT/GUARDIAN EMERGENCY CONTACT INFORMATION
Please use an asterisk (*) to indicate whom we should call first and the best number to reach you at.
Mother’s Name: ______________________ Business Phone: __________________
Home Phone: ________________________ Cel Phone/Pager: __________________
Father’s Name: _______________________ Business Phone: ___________________
Home Phone: ________________________ Cel Phone/Pager: __________________
OTHER EMERGENCY CONTACT INFORMATION
1) Name: ____________________________ Relationship: ______________________ Home Phone: ________________________ Business Phone: ___________________ Cel Phone/Pager: _____________________ Is this person authorized to pick-up your child: (circle one) YES / NO 2) Name: ___________________________ Relationship: _______________________ Home Phone: _______________________ Business Phone: ____________________ Cel Phone/Pager: _____________________ Is this person authorized to pick-up your child: (circle one) YES / NO
THIS SECTION FOR PARENTS/GUARDIANS
OF STUDENTS IN 9TH through 12TH GRADES ONLY!
Acetaminophen (Tylenol) 500 mg-1000 mg is available in the Health Room. Please make a selection from the options below. Your signature is required to authorize the school nurse or designated HBA personnel to administer the medication to your child.
Yes. You have my permission to administer Acetaminophen as needed, to my
No. Always contact me to get my verbal permission first, before any Acetaminophen
Parent/Guardian signature: _________________________________ Date: ________ Student’s Name: ________________________________ Date of birth:____________
Source: http://www.hba.net/files/content/about/news/announcements/middle_school_information/04_health_services_form.pdf
JØRGENSEN, Annette Myre; LÓPEZ, Juan A. Martínez. Los marcadores del discurso del lenguaje juvenil de Madrid. Revista Virtual de Estudos da Linguagem – ReVEL . Vol. 5, n. 9, agosto de 2007. ISSN LOS MARCADORES DEL DISCURSO DEL LENGUAJE JUVENIL DE Annette Myre Jørgensen1 Juan A. Martínez López2 RESUMEN : En este trabajo describimos un aspecto concreto del lenguaje juvenil: e
Pubblicazioni scientifiche internazionali DOTTORANDI Scienze Tecnologie Biofisiche DOTTORANDI Nanobiotecnologie Full Length Papers_ SCI with Impact Factor 1. Lelli M., Marchisio O, Foltran I, Genovesi A, Montebugnoli G, Marcaccio M, Covani U, Roveri N. Different corrosive effects on hydroxiapatite nanocrystals and amine fluoride- based mouthwashes on dental titanium b