PLEASE RETURN TO SCHOOL CONSENT FOR SCHOOL HEALTH SERVICES LAUREL COUNTY SCHOOL DISTRICT SCHOOL YEAR 2013-2014
SCHOOL: __________TEACHER:_______________ GRADE:_____ TEAM:_________ Student’s Last Name_________________ First Name________________ MI ____ (Please give child’s complete legal name) Student’s Social Security #________________________ Birth Date____________ Male ___ Female___
How many people live in the home:__________
___Yes, I give my consent for my child ______________________________to receive services at the School Clinic. NAME OF STUDENT ___No, I do not wish my child, _________________________________to receive services at the School Clinic. NAME OF STUDENT By signing this consent I release the Laurel County School District/Board of Education from any liability related to the administration of medication or treatment so long as Reasonable and Customary care is provided. ____________________________________ ____________________ * Parent/Legal Guardian Signature If you do not complete this form and return it to your child’s teacher at the school site the Nurse will not be allowed to care for your child EXCEPT in a true emergency situation. Assignment of Benefits: I request that payment of authorized medical insurance benefits be made to Laurel County School District on my behalf for services rendered to my child. I also authorize the local school district to release medical information about me to Medicaid, Medicare, insurance and/or other third party payors to determine payment for services. I have read this statement and understand that my signature indicates that I do consent and assign benefits as stated above. I also authorize the Laurel County School District Nurse providing services at the school clinic to provide health information from my child’s medical record to and from the designee of the school and my child’s physician only as needed under the guidelines of HIPPA and FERPA consistent with Federal Laws for the purpose of providing safe and appropriate school health services and programs. __________________________________________________ ______________________ * Parent/Legal Guardian Signature Street Address:_______________________________________________ City___________________ Zip__________ Mother’s Name___________________________ Hm Ph_______________ Wk Ph. _____________ Cell Ph_____________ Father’s Name____________________________ Hm Ph _______________ Wk Ph _____________ Cell Ph_____________ Legal Guardian____________________________ Hm Ph _______________ Wk Ph _____________ Cell Ph ____________ Free or Reduced Lunch Yes No
EMERGENCY CONTACT: (cannot be the same as those listed above) _________________________ ___________ _________ __________ _________________ Name of Emergency Contact
Home Phone Work Phone Cell Phone Relationship to Student
Student’s Medical Insurance KY Medical Card Yes
Provider Number:______________ MCO Provider _____________
Company:______________ Policy #:________________________
This allows the school district to bill your insurance for services provided to your child in school. You will NOT be billed for any service or balances not paid by insurance
PLEASE TURN THE FORM OVER AND COMPLETE THE BACK SIDE Student’s Medical History The following information will aid the School Nurse in making an accurate assessment of your child in case of illness or emergency. Please check the appropriate space if your child has ever had any of the following: ____
If you answered yes to any of the above please explain:______________________________________________________________ ____________________________________________________________________________________________________________ Please specify if any of the student’s family members have had any of the listed health problems by using this code: S-Sibling, F-Father, M- Mother, GF-Grandfather, GM-Grandmother and also identify the Grandparent by P-Paternal or M-Maternal (example: the mother’s parents would be listed as MGF for Maternal Grandfather) ____Cancer ____Anemia _____Kidney Disease _____Tuberculosis _____Heart Disease _____Birth Defects ____Epilepsy ____ Stroke _____ High Blood Pressure _____Diabetes Student’s Medications taken on a regular basis__________________________________________ You will be asked to complete a separate Medication Consent form if you desire the School Nurse to administer this medication in the School. Student’s doctor:____________________ Address ______________________________________ Student’s dentist:____________________ Address:______________________________________ _____Any Operations (if so please specify)___________________________________________________________________________ Type Surgery Where Physician Date _____Any Hospitalizations (if so please specify)_______________________________________________________________________
_____Any serious injuries or illnesses (if so please specify)______________________________________________________________ Type of Injury or Illness Physician Date When was the last time your child was seen by a doctor?________________________________________________________________ Doctor’s Name Reason Date
Student’s allergy to FOOD, MEDICATIONS OR ENVIRONMENTAL POLLENS? Yes__ No__ IF YES, PLEASE LIST:_____________________________________________________________ _________________________________________________________________________________ Have there been any recent upsets in the family that might affect your child? Yes__ No__ If you answered yes please explain:____________________________________________________________________________ Does your child use any of the following substances: Tobacco Yes__ No__ Alcohol Yes__ No__ Drugs Yes__ No__ ========================================================= The following list of medications will be on hand at the School Clinic and may be administered only by the School Nurse after
she has evaluated your child’s complaint. Please review the following list of medications and place a (√ ) by the ones you will allow your child to have: Acetaminophen (Generic name for Tylenol)
Ibuprofen (Generic for Advil and Motrin) ____
Diphenhydramine (Generic name for Benadryl)
Hydrogen Peroxide (for wound cleansing) ____
Children’s Pepto/Calcium Carbonate (Tums)
LCSD/FORM 15 Rev 07/2013
YOGA ASSOCIATION OF ALBERTA TEACHER DIRECTORY 11759 GROAT ROAD, EDMONTON, ALBERTA T5M 3K6 (780) 427-8776; www.yoga.ca; yaa@yoga.ca Last Name First Name Directory (For abbreviations see www.yoga.ca/directory.htm) Loca- tion Prof. Yoga Therapist, 200 hr. IYT Teacher Trainer, THRIVE! NaturallyYAA. Prenatal w/ emphasis pelvic floor awareness, strengthening,YAA. 23 yrs of practice. Cur
[Name of Clinic] [Name of Doctor] Patient Name: ____________________________________________________ Date: ____________ Review of Systems Have you had any of the following pulmonary (lung-related) issues? □ Asthma/difficulty breathing □ COPD □ Emphysema □ Other ____________ □ None of the above Have you had any of the following cardiovascular (heart-related)