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Mps.hams.schoolfusion.us

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

Source: http://mps.hams.schoolfusion.us/modules/groups/homepagefiles/cms/750513/File/ENROLL%202013-2014/MPS%20Grade%20Pk-12%20Health%20Emerg-Asthma%20Severe%20Allergy%20Form%20rev.%20Dec.12.pdf?sessionid=b132db9744972e3a59cd6e17eb6fbe15

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