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Health Information
This card must be updated the beginning of each school year.
Student Name
*
First
Last
Birthdate
*
Date Format: MM slash DD slash YYYY
Grade
*
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Medications
Will medications be needed at school?
*
yes
no
If medications are needed, in addition to this form, please fill out the proper prescription or over-the-counter permission forms located on our website under Resources >Health Office. For prescription medication, please print the Prescription Medication Form and take to your local provider to complete. Completed permission forms must be turned into the health office before medication can be administered.
List ALL medications - prescription and over-the-counter
Allergies
Does your child have any of the following life threatening allergies?
*
Select All
Bees/Insects
Latex
Food
Nuts
Other
None
If your child has a life threatening allergy, state law requires that you have a “Colorado Allergy & Anaphylaxis Emergency Care Plan” filled out by your child’s provider. Please see the Kate Michaels, RN, for this paperwork.
If you answered in the affirmative to any allergens above, please describe:
What medication is required for treatment of this allergy?
Select All
EpiPen
Benadryl
Other
If you answered "other" above, please describe below:
Asthma
Does your child have asthma?
*
yes
no
Does your child have an inhaler?
*
yes
no
Does your child need an inhaler at school?
*
yes
no
Last time inhaler was used?
Health Concerns
Check any that apply
ADD/ADHD
Bladder Problems
Blood Disorder
Diabetes
Head Injury
Hearing
Heart Disorder
Migraines
Muscle/Bone/Joint
Seasonal allergies
Seizures/Neurological
Skin rashes
Stomach/Intestinal/Bowel
Wears glasses/contacts
Other health concerns
If you checked any of the above, please list any medications, treatments, therapies, activity restrictions, and/or medical equipment needed in school:
Any significant changes in your child’s health over the last year? Explain:
Illnesses/Hospitalizations/Accidents/Injuries: List and give approximate dates:
Health Care Provider
*
First
Last
Provider Phone
*
Parents/Guardians are expected to transport student home or to the doctor/hospital when ill. In case of serious illness or injury, all emergency numbers provided to CSD will be called. If parent/guardian/emergency contacts cannot be reached, school personnel will immediately call 911 and request emergency health personnel to arrange for transporting the student to an emergency facility. If medication is to be taken at school, a completed Permission for Medication Form must be on file in the Health Office before it can be given. Any medication brought to school must be done so by a parent or guardian, NOT by the student. This includes all prescription medications, as well as over-the-counter and herbal remedies. All medications MUST be kept in the Health Office. Exceptions may be granted on a case-by-case basis with approval only, please contact the school nurse for more information. The CSD nurse accesses the Colorado Immunization Information System (CIIS), a confidential web-based system that collects and consolidates immunization information for disease control purposes. The CSD health office uses CIIS as a tool to ensure that your child has the proper immunizations required for school. This includes entering immunization data that the school has on file in a student’s health record which may not be listed on CIIS. If you do not want your child’s immunization data to be entered on CIIS, you may choose to opt out by notifying the school nurse in writing at the beginning of the school year.
I have read and understand the above information, and can get more information about CSD health policies in the Student Handbook, on the school website, or by contacting the school nurse. I give permission for the health information contained on this Health Information Card, to be shared with adults in the school setting that will be working with my child, on a need to know basis. It is the responsibility of the parent/guardian to notify the school nurse whenever there is any change in the student's health status or care.
*
I have read, understand and consent.
Parent Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
Home
About Us
Administration
Faculty
Contact
Employment
Activities
Academic & Athletic Programs
Clubs and Groups
Community Sponsored Programs
Board
Board News
Directors and Offices
District Policies
Meeting Agendas
Meeting Minutes
Strategic Plan Goals
Calendars
Calendar of Events
District Calendar
Family
Absence
Creede Early Learning Center
Free & Reduced Lunch Application
Grievance Form
Health Office
Hot Lunch
Late Start and Closing Procedures
Newsletters
Parent and Student
Parent Teacher Organization
Registration
Annual Agreement Forms
Enrollment Form
Student Housing Questionnaire
Transportation Contract – Mineral County Residents Only
Restorative Practices
School Supplies
Title IX
Student
College Guidance
Dance Guest Pass Form
Parking Permit
Senior Student Early Dismissal Application
Transcript Request
Teacher
Accident Report
Facility Use Request Form
Maintenance Request
Purchase Requisition
Staff Evaluation Procedures
Teacher Resources
Transportation/Field Trip Request
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