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Health Services Form 2020-2021

This information is necessary for the health and safety of your child.  The information will assist in promoting optimal healthcare to facilitate your child's success.  Thank you for your time.

*Required fields marked with an asterisk (*)

Gender:*
Answer Required

Address

State*
Answer Required

Contact Information of Parent/Guardian #1

Contact Information of Parent/Guardian #2

My child lives with: *
Answer Required

Disease/Disorder History 

Please check the box if any of the following apply to your child: *
Answer Required
Was a medical evaluation performed for any condition/disorder (above) that was checked "Yes" *
Answer Required

Disease/Disorder History (cont'd)

Seizures

For our students who are under a doctor's care for a seizure disorder, a Seizure Action Care form will need to be completed by the doctor to ensure a safe school environment for your child.   This form can be obtained from our nurse. 

Seizures: Is your child currently under a doctor's care for seizures?*
If "yes," then please answer the next question as well.
Answer Required
Seizures: If your child is currently under a doctor's care for seizures, are rescue medications prescribed?
If "yes", then please answer the next question as well.
Answer Required
Seizures: If rescue medications are prescribed for your child's seizure disorder, which one?
If "yes," then this medication must be brought to school in a pharmacy labelled bottle/box with a med order from your doctor.
Answer Required

Disease/Disorder History (cont'd)

Allergies

For our students who are under a doctor's care for severe allergies, an Allergy Action Plan form will need to be completed by the doctor to ensure a safe school environment for your child.  This form can be obtained from our nurse. 

Is your child allergic to any medications and/or supplements?*
If "yes," then please answer the next question as well.
Answer Required
Is your child allergic to any food(s)?*
If "yes," then please answer the next question as well.
Answer Required
Is your child allergic to anything in the environment (e.g., pets, insects, pollen, grass, airborne chemicals).*
If "yes," then please answer the next question as well.
Answer Required
Is your child currently under a doctor's care for a severe allergy?*
If "yes," then please answer the next two questions as well.
Answer Required
Allergies: Was an Epi-Pen prescribed for your child's severe allergy?
Answer Required

Disease/Disorder History (cont'd)

Diabetes and Asthma

For our students who are under a doctor's care for diabetes and/or asthmaa Diabetic Medical Management form and/or an Asthma Action Plan form will need to be completed by the doctor to ensure a safe school environment for your child.  These forms can be obtained from our nurse. 

Diabetes: Is your child currently under a doctor's care for Diabetes?*
If "yes," then please answer the next question as well.
Answer Required
Diabetes: My child is currently under a doctor's care for the following type of Diabetes:
Answer Required

Medication History

Does your child currently take medication on a daily basis?*
(this includes CBD Oil/Medical marijuana, and any nutritional supplements
Answer Required
Will your child need to take medication on a daily basis AT SCHOOL?*
Answer Required

If you answered "Yes" to the above question, you MUST obtain a medication order from your child's doctor and either fax to Nurse Renee @ (724) 728-4520 or send to school in your child's folder. 

*This must be completed at the beginning of each school year. 

**Medication must be sent to school in a bottle labeled by a pharmacy (with your child's medication order).  

I give permission for the following medications to be administered to my child during school:*
(please remember that as per PA State Law, our school nurse CANNOT administer medical marijuana or CBD oil).
Answer Required

Social History 

Has there been any changes in your family during the past year such as:*
(check all that apply)
Answer Required

Miscellaneous

In order to provide the safest learning environment for our students and staff, we require our students to enter the building everyday via our "walk-through" metal detectors. Does your child have any medical conditions/restrictions that prevent him/her from walking through our metal detectors? *
Answer Required
The school nurse has my permission to share my child's confidential health information, on a need-to-know basis, with appropriate members of the educational staff and primary healthcare providers for the legitimate educational interest in meeting the educational and health needs of my child.*
Answer Required

Consent to Share Information

Confirmation Email