Health History Update, Permission for Emergency Care & Extended Day Registration

Student First Name: *

Student Last Name: *

Nickname:

Sex: *

Date of Birth: (MM/DD/YYYY) * +

Grade: *

School Year: *

Street Address: *

City: *

State: *

Zip Code: *

Name and grade of any siblings at school:

Student Lives With: *

Mother/Guardian First & Last Name: *

Marital Status

Mother/Guadian Cell Phone #: *

Mother Home Phone #:

Mother Work Phone #:

Mother/Guardian email address: *

Mother's Occupation

Employer

Father/Guardian First & Last Name:

Marital Status

Father/Guardian Cell Phone #:

Father Home Phone #:

Father Work Phone #:

Father/Guardian email address:

Father's Occupation

Employer

Child's Physician: *

Physician Phone Number: *

Insurance Company: *

Policy #: *

Complete the following checklist by indicating any of the *

Provide details for all items above marked YES:

If allergies are listed above, please describe the actions to take for each.

Does the student's health condition require medically necessary medications or specialized health care treatments in school?

Yes

No

Does the student take any medications, homeopathic supplements or nutritional & performance supplements? *

Yes

No

If yes, please explain:

Specifically during or after exercise, has the student experienced any of the following? Check all that apply. *

Was a medical evaluation done as a result of any of the above symptoms during exercise?

Yes

No

If yes, what was the outcome of the evaluation?

Date of last tetanus shot *

**Please do NOT list a parent as an emergency contact. This should be a person we can call if we cannot get a hold of a parent!**

Emergency Contact #1 First & Last Name: *

Relationship to Student: *

Emergency Contact #1 Street, City, State, Zip: *

Emergency Contact #1 Phone Number(s): *

Emergency Contact #2 First & Last Name: *

Relationship to Student: *

Emergency Contact #2 Street, City, State, Zip: *

Emergency Contact #2 Phone Number(s): *

List any additional people who ARE allowed to pick your student up from school:

List any people NOT authorized to pick up the student from school. If this does not apply, please write N/A. *

Please list any previous child day programs attended. If this does not apply, please write N/A. *

Consent for Treatment: I give my permission for qualified school personnel to provide routine health care and first aid to my child as may be necessary during school and after school activities. I assume full responsibility for providing the school with all necessary over the counter or prescription medications as well as necessary medical treatment supplies and authorization, if needed during the school day.

Consent for Treatment: *

Yes

No

Consent to Share Health Information: The school nurse and/or health aide have my permission to share my child's confidential health information, on a need-to-know basis, with appropriate members of the educational staff (e.g. teachers, counselors, athletic trainers, extended day staff), and healthcare team, for the use in meeting the educational and health needs of my student. This consent includes the sharing of personally identifiable health record information during immunization and communicable disease surveillance audits by the Virginia Department of Health and the Virginia Department of Social Services for licensed program compliance, if applicable.

Consent to Share Information: *

Yes

No

Notification Agreement: I agree to notify the school within 24 hours if my child or any member of their immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, when a physician deems necessary for the well-being of my child.

Notification agreement: *

Yes

No

Consent to Share Information: I grant permission for the following information to be made available to the St. Ambrose School community: student and parents' names, address, phone number and email address.

Consent to Share Information: *

Yes

No

Consent to Participate: I grant permission for my child to use all play equipment, walk around school grounds for planned activities, and to participate in all activities held at the school.

Consent to Participate: *

Yes

No

I certify that the information provided in this document is true and accurate to the best of my knowledge.

Parent/Guardian Signature: *

clear

Parent Printed First & Last Name: *

Date * +

Allergies/Environmental	Allergies/Food	Allergies/Insect stings or bees
Allergies/Latex	Allergies/Medications	Allergies/Other
Asthma/Breathing Problem	Behavior problem	Bladder/Kidney disorder
Bleeding/Clotting disorder	Bone/Joint/Muscular disorder	Cancer
Convulsions/Epilepsy/Seizure	COVID 19	Depression
Dental problem	Developmental problem	Dizziness or Fainting
Diabetes	Dietary restriction	Digestive/Bowel problem
Eating disorder	Endocrine disorder	Head or Spinal injury
Headaches/Migraines	Hearing problem	Heart defect or disease
Hepatitis or Liver problem	Hernia	Hypertension
Immune System disorder	Infectious disease, current	Infectious disease, inactive
Lead poisoning	Menstrual problem	Mobility limitation
Mononucleosis	Orthodontic treatment	Physical education restriction
Psychological/Emotional problem	Scoliosis	Skin condition
Soiling/Incontinence	Speech disorder	Surgery or Hospitalization
Tuberculosis	Vision or Eye disorder	Weight concern (over/under)
Other: (explain below)	N/A

Fainting/passing out	Extreme shortness of breath	Heat stroke
Chest pain	Sever lightheadedness/Dizziness	Coughing/Wheezing
Excessive bruising	Numbness/Tingling	N/A