Clarksville Community School

Student Medical Information

Family Doctor & Telephone Number: ______

Does the student have: / No / Yes / No / Yes
ADD / ADHD / Takes medication for ADD/ADHD?
Allergies (food, medication, environmental) / Headaches / migraines?
Asthma / Uses for asthma? (inhaler / nebulizer / both)
Diabetes / Needs blood sugar monitored / insulin at school?
Vision problems? (right / left / both) / Hearing problems? (right / left / both)

List below any allergies, medicines, and other medical concerns: (ex: glasses/contacts/headaches/heart problems)______

______

Note to parents: Health Information is shared with school staff. Please list all information that we should know about.

INTERNET APPROPRIATE:

Your child has access to the Internet. Students will be able to access the Internet under their teacher’s supervision. Students will be expected to abide by the following network etiquette and guidelines:

  • The use of the network is a privilege and may be taken away for violation of board policy or regulations. As a user of the internet, students may be allowed access to other networks. Each network may have its own set of policies and procedures of these other networks.
  • Students will respect all copyright and license agreements.
  • Students will cite all quotes, references, and sources.
  • Students will only remain on the system long enough to get needed information.
  • Students will apply the same privacy, ethical, and educational considerations utilized in other forms of communication.
  • Students accessing Internet services that have a cost involved will be responsible for payment of these costs.
  • Student access for electronic mail will be through the supervising teacher’s account.

a) Others may be able to read or access the mail, so private messages should not be sent.

b) Delete unwanted messages immediately.

c) Use of objectionable language is prohibited.

d) Always sign messages.

e) Always acknowledge receipt of a document or file.

ETHNICITY INFORMATION:

Is this student Hispanic / Latino? O No O Yes

RACE: What is your race? (check one or more)

OWhite

OBlack or African American

OAsian

ONative Hawaiian or Pacific Islander

OAmerican Indian or Alaska Native

1. What language did your child speak when he / she first began to talk? O English O Other

2. What language does your child speak most often at home? O English O Other

3. What language does your child speak most often with his / her friends? O English O Other

4. What language do YOU use most often speak when speaking to your child? O English O Other

5. What language do YOU use most often when speaking with your friends? O English O Other

6. What language do other family members in your home usually use when speaking to each other? O EnglishO Other

MILITARY CONNECTED STATUS

Please mark the appropriate statement

ONeither Parent or Guardian is serving in any military service.

OA Parent or Guardian is serving in the National Guard but is not deployed.

OA Parent or Guardian is serving in the Reserves but is not deployed.

OA Parent or Guardian is serving in the National Guard and is currently deployed.

OA Parent or Guardian is serving in the Reserves and is currently deployed.

OA Parent or Guardian is serving in the military on active duty but is not deployed

OA Parent or Guardian is serving in the military on active duty and is currently deployed.

OThe student’s Parent or Guardian died while on active duty within the last year.

Parent / Guardian Signature______Date: ______