STUDENT HEALTH INFORMATION
STUDENT NAME: _____________________________________________________________
GRADE: _______
AGE: _______
If student is on any routine medications please list: _______________________________________________________________________________ ___________________________________________ Do we need to give it at school? _________
ALLERGIES: _______________________________________________________________________________ _______________________________________________________________________________
ANY CHRONIC HEALTH PROBLEMS SUCH AS EYESIGHT, HEARING, ASTHMA, DIABETES, ETC:
_______________________________________________________________________________ _______________________________________________________________________________
NAME and PHONE # TO CONTACT IN EMERGENCY, IF PARENT CANNOT BE REACHED:
_______________________________________________________________________________
I hereby grant permission for Banner County School Personnel to dispense non-prescription medication when deemed necessary for the well-being of above named child. I grant permission for information regarding allergies, asthma, etc., to be given to teachers. I grant permission in the event that an illness or accident might occur when a parent is not available, for the school to secure medical attention. Any exceptions to this permission? _____________ ________________________________________________________________________________ ________________________________________________________________________________ PARENT’S or GUARDIAN’S SIGNATURE
THANK YOU FOR YOUR HELP! Marie Parker, RN School Nurse
