Fair Lawn Public Schools

FAIR LAWN PUBLIC SCHOOLS

FAIR LAWN, NEW JERSEY 07410

HEALTH INFORMATION

PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE
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Student's Name: (LAST) (FIRST) (M.I.) (Grade)
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Student's Date of Birth: Sex: ( )M ( )F State or Country of Birth:
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Student's Address: City: State: Zip:
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Mother's Name/Legal Guardian : Home Phone: Cell Phone: Wk: Phone
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Father's Name/Legal Guardian: Home Phone: Cell Phone: Wk: Phone
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Others who may be contacted to pick up your child if you are unable to be reached: (Please list two)
Name: ______Home Phone:______Cell Phone:______Wk. Phone:______
Name: ______Home Phone:______Cell Phone:______Wk. Phone:______
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Student's Medical Provider: Address: Phone:
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Additional Medical Specialists: Address: Phone:
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Does your child have health insurance? ( ) No* ( ) Yes - Name of Ins. Co.:______
* NJ Family Care provides free or low cost health insurance for uninsured children and certain low income parents. Please contact 1-800-701-0710 or visit to apply. We may release your name to the NJFamilyCareProgram to contact you regarding health insurance.
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Mychild has a medical, emotional or behavioral condition that may affect his/her school day: ( ) No ( )Yes -please describe:
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PART 2: COMPLETE ALL BOXES THAT APPLY TO YOUR CHILD
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( ) ALLERGIES - If box is checked please list type and reaction:
Allergy Type:
( ) Food (list food(s))______
Reaction: ______
( ) Insect Sting (list insect(s))______
Reaction: ______
( ) Medication (list medication(s))______
Reaction:______
( ) Other (list other)______
Reaction:______
Medications Prescribed:
( ) Oral antihistamine (Benadryl, etc.) ( ) Epi-pen ( )Epi-pen Jr. ( )Other: ______
( ) ASTHMA
( )eNVIRONMENTAL (I.E., TOBACCO, DUST, PETS, POLLEN , ETC.) ______
( )wEATHER: (i.e. hEAT, COLD, HUMIDITY) ______
( ) EXERCISE: ( ) yES ( ) nO
( ) oTHER: (i.e. sprays, SMELLS ) ______
Medications Prescribed: ______
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( ) SEIZURE DISORDER:
Type: ( ) Absence ( ) Complex Partial ( ) Generalized/ Tonic Clonic ( ) Other: ______
Physical Education Restrictions Per MD: ( ) No ( ) Yes - ______
Date of Last Seizure:______Hospitalized: ( ) No ( ) Yes
Medications Prescribed: ______
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( ) OTHER HEALTH OR EMOTIONAL CONDITIONS: Please check all that apply:
( ) anemia ( ) anxiety ( ) Add/Adhd ( ) behavioral ( )cancer ( ) cerebral palsy ( ) chicken pox ( )cystic fibrosis
( )depression ( ) digestive disorders ( ) hemophilia ( ) heart ( ) juvenile rheumatoid arthritis ( ) speech
( )sickle cell ( ) skin disorders ( ) other - explain ______
Medications Prescribed: ______
Has your child ever had any hospitalizations? ______
Has your child ever had any fractures, if so please list?______
Does your child have an IEP or 504 Plan? ( ) NO ( ) YES -Explain______
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( ) SPECIAL PROCEDURES REQUIRED: (I.E. CATHETERIZATION, OXYGEN, GASTROSTOMY CARE, TRACHEOSTOMY CARE, ETC.)
( ) NO ( ) YES (explain) ______
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( ) VISION CONDITIONS: ( ) HEARING CONDITIONS:
( ) Contacts/Glasses ( ) Hearing aid (s)
( ) Other ______( ) Other ______
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Is there any other information that you wish to share with us? ______
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Parent/Legal Guardian Signature Date
The school nurse may share any and all health information necessary with the faculty unless instructed otherwise.