Platte Canyon School District No. 1
HEALTH AND EMERGENCY INFORMATION 2009-2010
To be completed annually and turned in with all other registration materials
Fill in Fields, Print Form, Sign & Mail to:
Platte Canyon School District     Attention: Shelly Carlstrom
57393 U.S. Highway 285      Bailey, Colorado 80421


Student Name
Date

Health Care Provider/Insurance Information:


School
Grade
Male or Female
Birth Date


Doctor
Phone

Dentist
Phone


Hospital Preference

Type of Insurance

If your family does not have insurance, please call Park County Public Health Dept. at 303 -816-5936 for information on obtaining low cost health insurance for your children.


Health Information

 Past Present If YES , diagnosis? / Please explain:
    Autism
    Asthma/Respiratory Difficulties
    ADHD or ADD

    List Allergies
    Bladder/Kidney Problems
    Bowel Problems (constipation, diarrhea ,colostomy, etc.)
    Blood Disorders
    Cancer
    Diabetes
    Eating Disorder
    Frequent Headaches
    Frequent Ear Infections
    Frequent Throat Infections
    Genetic Condition
    Head Injury
    Hearing Loss/Hearing Aids
    Heart Problems
    Hospitalization/Surgery
    Neurological Disorder (spina bifada muscular dystrophy, tremors, , ect.)
    Physical Disability (bone, joint, arthrit is, muscle problems, cerebral palsy, etc.)
    Psychiatric Disorder
      Under Dr’s care?
    Seizure Disorder
    Serious Accidents, Illnesses, Inju ry
    Shunts
    Skin problems
    Stomach/Digestive Problems
    Vision Problems (incl.glasses or contact s)
    Other


Health Concerns:

Have there been any concerns and/or changes in your child’s health over the last year?    Yes   No
If yes, please explain:

Restrictions:

Has the doctor restricted your child’s activities for medical l reason s?    Yes   No
If yes, please explain:


NOTE:  A physician’s note is required to excuse your child from physical education classes.

Medications/Medical Procedures:

1.  Does your child require any specific medical equipment at school (i.e. wheelchair, feeding tube, nebulizer, oxygen, etc.)?    Yes   No
If YES, please explain:

2.  Has your child required any routine, long-term medications in the past?    Yes   No
If YES , please explain what medications, for what condition and how long?

3.  Does your child currently take daily medications ?    Yes   No
If YES, please list (including Medication name, dosage and frequency)

4.  Will your child require medication during school hours?    Yes   No
If YES, please complete medication permission form.

PLEASE READ COMPLETELY AND CAREFULLY:

In accordance with the Colorado State Medication Guidelines, Platte Canyon School District will administer prescription and over the counter medications (including cough drops, acetaminophen, ibuprofen, cough/cold medicine etc.) with written parent and physician permission.   It is the parent/guardian’s responsibility to furnish the medication.   In order to assure the safety of students, ALL medications must be brought to school by a parent/guardian and must be in the original container.   Prescription medications must come in the original container labeled with: child’s name, name of medicine, times medicine is to be given, dosage, pharmacy name and number and physician’s name.   Initials __________

I give permission for school personnel to apply sunscreen to exposed skin areas, petroleum jelly to lips and hand lotion as needed.   Initials __________

I understand the above health information may be shared with school personnel if it is determined that the information provided may impact the student’s educational experience and/or safety.   I give permission for this information to be shared with school personnel as deemed necessary.   Initials__________

I, the undersigned, authorize officials of Platte Canyon School District to contact the above named physician and/or emergency medical system when deemed necessary, in their judgement, for the health of aforementioned child.   In an emergency situation, I authorize emergency medical system personnel, the above named physician and/or physician of nearest emergency medical facility to render treatment as may be deemed necessary.   Reasonable efforts will be made to contact parent/guardian or emergency contacts.   I will not hold Platte Canyon School District financially responsible for expenses incurred, as a result of emergency ambulance use or treatment by physician and/or emergency medical facility.   Initials_________

I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL RELEASE

Parent/Guardian’s Signature _________________________________________________
Date ___________________