MILLARD PUBLIC SCHOOLS HEALTH/EMERGENCY FORM
THIS SIDE MUST BE REVIEWED YEARLY.
Student ________________________________________________ Male ___ Female ___ DOB ______________
Address __________________________________________________
Please list any Health Issues or Allergies that we should be aware of: ____________________________________
_____________________________________________________________________________________________
Medications taken at home: ______________________________________________________________________
Medications taken at school: _____________________________________________________________________
In case of an emergency or illness, list all numbers where you can be reached: _____________________________________________________________________________________________ Mother’s Name Work Place/Hrs. _____________________________________________________________________________________________ Father’s Name Work Place/Hrs. Wk. Phone # Cell Phone # _____________________________________________________________________________________________ Legal Guardian’s Name Work Place/Hrs. Wk. Phone # Cell Phone # Custodial Parent: (if legal custody has been set)
Birth/Adoptive Mother_______ Birth/Adoptive Father_______ Both______ Legal Guardian_______ In case of an emergency, and the above can’t be reached, I authorize the school district to contact and release the student to the following persons in the order designated:
_____________________________________________________________________________________________ Name
_____________________________________________________________________________________________ Name
Daycare Provider: ________________________________________ Phone #_____________ Cell # ____________
Physician: ____________________________________________________ Phone #___________________
Dentist: ______________________________________________________ Phone #___________________
Life threatening health information will be shared with building staff members who work with your student. If you do not want to have non-life threatening health information shared with staff members, other than the principal and school nurse, please send written documentation to the school nurse. During normal school hours in life threatening situations, 911 will be called. If severe Asthma or Allergic reaction occurs, 911 will be called, injected Epinephrine will be administered, followed by nebulized Albuterol. Please inform the school nurse in writing if your student has a medical condition that would require this not to be implemented. Parent/Guardian Signature (Required)____________________________________ Date __________ If your child has ASTHMA or SEVERE ALLERGIES, please fill out backside of this form
Rev. 12/2012 MILLARD PUBLIC SCHOOLS STUDENT ASTHMA/SEVERE ALLERGY INFORMATION MANDATORY YEARLY UPDATE
COMPLETE THIS SIDE ONLY IF YOUR CHILD HAS ASTHMA OR SEVERE ALLERGIES
Student ______________________________________________ Male ___ Female ___ DOB ________
Address __________________________________________________________ Phone _____________
Parent/Guardian _______________________________________________________________________
Physician Treating Asthma: ________________________________________ Phone _______________
Current status of your child’s Asthma (Please check one) Mild ___ Moderate ____ Severe ____
Does your child use an “as needed” Inhaler?
If Yes, Inhaler Name ___________________________________________________________________
Does your child require any medication at school for Asthma?
Does your child use a Peak Flow Meter? Yes ____ No ____ Students Normal Peak Flow’s Green Zone: ________________ Action: _________________
Yellow Zone: ________________ Action: _________________
Red Zone: ________________ Action: _________________
Asthma Medication(s) taken: ____________________________________________________________
____________________________________________________________________________________
Please identify the things that trigger an asthma episode for your child: ___________________________
____________________________________________________________________________________
SEVERE ALLERGY INFORMATION COMPLETE THIS ONLY IF YOUR STUDENT HAS SEVERE ALLERGIES
My child has a severe allergic reaction to the following: ______________________________________
____________________________________________________________________________________
Action taken for mild reaction: __________________________________________________________
Action taken for severe reaction: _________________________________________________________
Allergy medication(s) taken at home: ______________________________________________________
Allergy medication(s) taken at school: _____________________________________________________
Comments/Special Instructions: __________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________
Please submit medical Action Plan from physician if available Rev. 12/2012
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