Drummond Public Schools

DRUMMOND PUBLIC SCHOOLS

MEDICAL CONSENT AND INFORMATION FORM

Today’s Date ______

Full Legal Name ______Gender _____ Birthdate ______

Last First Middle

City and State of Birth ______Name Student Goes By ______

Previous School Attended ______

Previous School City ______State ______Present Grade ______

Child Resides w/ ______

Father/Stepfather (Name) Mother/Stepmother (Name) Guardian/Other

Physical Address______City ______State ______

Mailing Address______City______State______

Home Phone ______Cell Phone______Work Phone ______

(Dad) (Mom)

Email address______

I/We,______(__Parent, __Legal Guardian, __Other) hereby consent for School Personnel of School Districts #11 & #2 to arrange for or provide the following Health services for this child:

1.  Emergency medical care for an accident or illness, including non-surgical procedures, that cannot be deferred without endangering the child’s health or life.

2.  Routine medical care involving the provision of health services of preventive, diagnostic, therapeutic and/or rehabilitative nature that does not involve surgical procedures.

3.  Transport of the child to and from health facilities in case of emergency.

Signed: ______

Alternative Person to Notify in the Event of an Emergency ______Phone ______

For Illness or Injury Requiring a Doctor Call ______Phone ______

IF YOU WISH YOUR CHILD TO BE GIVEN TYLENOL UPON REQUEST, PLEASE MARK BELOW

_____ YES, my child may have Tylenol on request.

_____ NO, my child may NOT have Tylenol.

List all family members living in the household, including ages of children. ______

______

Information about this child’s medication, allergies, medical condition, surgery, fractures, etc.______

______

► Immunization information for ______will be shared with the local public health departments and entered into an electronic data system, the Montana Public Health Data System (PHDS). The intent of an electronic immunization registry is to provide a complete and permanent immunization record for your child.

Signed ______Dated: ______

THE McKINNEY HOMELESS EDUCATION ASSISTANCE PROGRAMS

108 W. EDWARDS – DRUMMOND, MONTANA 59832

CONTACTS: BRYAN KOTT 288-3281

Student Residency Questionnaire

This questionnaire addresses the McKinney-Vento Act 2001. Your answers will help determine services available.

1. Presently, where is the student living? Check one box:

Section A / Section B
 in a shelter
 doubled up with another family in their house or apartment
 in a motel, car or campsite
 with friends or family members (i.e. other than parent/guardian: kinship care)
 in transitional housing
Continue: If you checked a box in Section A, complete the rest of this form. /  Choices in Section A do not apply.

2. Student of Military Family (Please check one)

o  The United States Military (Army, Navy, Air Force, Marines, or Coast Guard

o  Active Duty National Guard

o  Active Duty Reserve Force of the US Military

o  Transitioning out of Active Duty to National Guard or Reserve

Race/Ethnicity Two-Part Question: Sample Format for Enrollment Forms