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.
___No, I do not wish my child, _________________________________to receive services at the School Clinic.
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.
____________________________________ ____________________


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
__________________________________________________ ______________________
* 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

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.
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


2009 membership current

YOGA ASSOCIATION OF ALBERTA TEACHER DIRECTORY 11759 GROAT ROAD, EDMONTON, ALBERTA T5M 3K6 (780) 427-8776;; Last Name First Name Directory (For abbreviations see 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

Microsoft word - review of systems sample.doc

[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)

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