Yearly Student Health Information Sheet 2020-2021

Central Cass Public Schools

To help us assist your child at school, please complete the following information.

Students Last Name *

Student's First Name *

Grade Entering *

Date of birth (MM/DD/YYYY) * +

Full Address *

Sex *

Male

Female

Check One *

Have Insurance	No Insurance
Medical Assistance	Healthy Steps

Student's Doctor *

Doctor's Phone Number *

Hospital Preference *

Language spoken at home *

Student's Dentist *

Dentist's Phone Number *

Mother/Guardian's Name *

Cell Phone Number *

Home Number:

Work Number:

Father/Guardian's Name

Cell Phone Number

Home Number:

Work Number:

Emergency Contact Name
(Other then listed above)

Cell Phone Number

Home Number:

Work Number:

Emergency: Does student have a known health problem which could result in an emergency (insect sting, seizure, diabetes, bleeding problem, heart condition, asthma, other, etc.) *

No	Yes: please list: Yes: please list:

Emergency Care Plan: Would you like an Emergency Care Plan on file for your student? *

No	Yes: please list for what health problem: Yes: please list for what health problem:

Medications: Please list medications taken regularly at home and/or school and reason:
Note: If medications or ECP is needed at school, parent must complete school concent form and have it signed by the licensed prescriber. Forms can be found at the school office, on our website, and at most clinics.

0/255 characters

Is the student currently served by an IEP or 504?

an IEP (Individual Education Plan)

a Section 504 accommodation plan

No neither

Health History

Mark the medical conditions that apply:

	Yes, Please specify:
Allergies	Yes, Please specify:	Yes, Please specify:
Asthma	Yes, Please specify:	Yes, Please specify:
Attention Deficit	Yes, Please specify:	Yes, Please specify:
Diabetes	Yes, Please specify:	Yes, Please specify:
Emotional Concerns	Yes, Please specify:	Yes, Please specify:
Hearing Concerns	Yes, Please specify:	Yes, Please specify:
Heart Concerns	Yes, Please specify:	Yes, Please specify:
Seizures	Yes, Please specify:	Yes, Please specify:
Special Diet	Yes, Please specify:	Yes, Please specify:
Vision Concerns	Yes, Please specify:	Yes, Please specify:
Wears Contacts or Glasses	Yes, Please specify:	Yes, Please specify:
Other	Yes, Please specify:	Yes, Please specify:

Comments or additional information you would like noted:

Over the Counter Medications

Permission to administer at school: *

Non-Aspirin

Tums

Check here if you do NOT want your child to have Non-Aspirin or Tums

Any notes you want added: Any notes you want added:

The undersigned parent or legal guardian and/or eligible student acknowledges that this Health Information Sheet and the content contained therein is an educational record, the disclosure of which is governed by Federal Educational Rights & Privacy Act (FERPA). In the event of any third-party billing, Health Insurance Portability & Accountability Act (HIPPA) is also followed. By signing below I give consent 1) to disclose the information contained herein only as authorized by such laws or regulations, and 2) to use such information to create Emergency Care Plans or to consult with a student’s Primary Care Provider for any health concerns as needed. I acknowledge I have been given the opportunity to review the Fargo Cass Public Health Notice of Privacy Practices, available at http://fargond.gov/city-governemnt/departments/fargo-cass-public-health

Parent/Guardian's Signature
(Sign using your mouse or trackpad) *

clear

Name of person submitting form: *

Relationship to child *

(Nurse Michelle's Use Only:)

Reviewed