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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