Trout Lake School

TroutLakeSchool

Student Emergency Information

Today’s Date______

Student's Name______Birth Date ______

Mailing Address ______Grade Entering______

Street Address (if different) ______

Home Phone______Student’s e-mail (if applicable) ______

Father's Name______Cell Phone ______

Father’s Address (if different) ______E-mail ______

Father’s Employer______Work Phone ______

Mother's Name______Cell Phone ______

Mother’s Address (if different) ______E-mail ______

Mother’s Employer______Work Phone ______

Alternate Persons to be notified in case of Emergency:

______Relationship ______Phone______

Any additional medical information can be written on a separate sheet if more space is needed.

Please include below any specific diagnoses as well as medications taken or prescribed.

DOES YOUR CHILD HAVE?

Allergies No Yes  Specify ______

Anxiety/Fears (unusual) No Yes  Specify ______

Anorexia/Bulimia/Obesity No Yes  Specify ______

Asthma No Yes  Specify ______

Blood Disorder No Yes  Specify ______

Cancer No Yes  Specify ______

Depression No Yes  Specify ______

Diabetes No Yes  Takes Insulin No Yes 

Ear Infections No Yes  Date of Last Infection ______

Epilepsy or Seizures No Yes  Date of Last Seizure ______

Heart Condition No Yes  Specify ______

Insect/Bee Sting Allergy No Yes  Local Reaction General Reaction 

Kidney Disease No Yes  Specify ______

Migraines No Yes  Specify ______

Orthopedic Problem No Yes  Specify ______

Headaches No Yes  Specify ______

Nervousness No Yes  Specify ______

Other Illness/Condition No Yes  Specify ______

Continued on the following page

HAS YOUR CHILD HAD?

Serious IllnessNo Yes  Specify Type & Date ______

Serious InjuryNo Yes  Specify Type & Date______

Surgery (Operations)No Yes  Specify Type & Date ______

DOES YOUR CHILD HAVE?DOES YOUR CHILD?

Trouble Seeing Close Work No  Yes Wear GlassesNo Yes 

Trouble Seeing At Distance No  Yes Wear ContactsNo Yes 

Trouble Hearing No  Yes Wear Hearing AideNo Yes 

Does your child have a condition that prevents participation in regular P.E. (running, push-ups, wrestling, contact sports, etc)? No  Yes  Specify ______

May your child receive blood products in case of an emergency? No  Yes 

Does he or she take daily medication? No Yes 

If yes, specify ______

Does your child need to take medication during school hours? No  Yes 

If yes, specify:______

NOTE: If you answered yes to this, please get the appropriate paperwork from the school office so medication administration can be set up for your child as soon as possible. In compliance with state law, school district regulations require parent permission and physician authorization for taking medication at school.

Does your child need to have any medical or physical restrictions? No  Yes 

If yes, specify______

Does your child require any specific medical equipment/medical/nursing procedures at school?

No Yes If yes, specify______

Do you have medical insurance for your child? No Yes 

Insurance Information:

Name of Insurance ______Group Number______

Insured Person (parent)______Policy Number______

Physician of 1st choice______Phone______

Preferred Hospital______Phone______

Is there any other pertinent medical information on your child?No Yes 

If yes, specify______

______

Any changes in medical condition and/or treatment should be reported to the school immediately.

If the parent/guardian cannot be reached at the time of an emergency, and if immediate observation or treatment is urgent in the judgement of the school authorities, do you authorize and direct the school authorities to send the student (properly accompanied) to the hospital or doctor most easily accessible to provide medical treatment, including x-ray exam, medical or surgical diagnosis or treatment and hospital care? No  Yes 

If no, specify what you want done: ______

______

Do you agree to be financially responsible for all expenses incurred for treatment under the circumstances described above, including ambulance services if needed? No Yes 

______

Signature of Parent or Legal GuardianDate

Health and Medical Information reviewed by the School Nurse:

RN Signature ______Date______