Health History Update & Permission for Emergency Care

 +
Complete the following checklist by indicating any of the *
Does the student's health condition require medically necessary medications or specialized health care treatments in school?
Does the student take any medications, homeopathic supplements or nutritional & performance supplements? *
Specifically during or after exercise, has the student experienced any of the following? Check all that apply. *
Was a medical evaluation done as a result of any of the above symptoms during exercise?
Consent for Treatment: I give my permission for qualified school personnel to provide routine health care and first aid to my child as may be necessary during school and after school activities. I assume full responsibility for providing the school with all necessary over the counter or prescription medications as well as necessary medical treatment supplies and authorization.
Consent for Treatment: *
Consent to Share Information: The school nurse and/or health aide have my permission to share my child's confidential health information, on a need-to-know basis, with appropriate members of the educational staff, primary healthcare providers, and extended day, for the use in meeting the educational and health needs of my student. This consent includes the sharing of personally identifiable health record information during immunization and communicable disease surveillance audits by the Virginia Department of Health and the Virginia Department of Social Services for licensed program compliance, if applicable.
Consent to Share Information: *
Notification Agreement: I agree to notify the school within 24 hours if my child or any member of their immediate household has developed a communicable disease. I agree to notify the school immediately if the disease is life threatening. I agree to pick up my sick or injured child in a timely manner when contacted. If I cannot be reached, the above emergency contacts can be called to pick up my child. Additionally, if I cannot be contacted in an emergency, the school has my permission to take my child to the emergency room of the nearest hospital and I hereby authorize its medical staff to provide treatment, when a physician deems necessary for the well-being of my child. 
Notification agreement: *
I certify that the information provided in this document is true and accurate to the best of my knowledge.
Parent/Guardian Signature: *
clear
 +
Powered byFormsite