595.01
Health condition or conditions which may require special care: _____________________________________________________________________
ELMIRA CITY SCHOOL DISTRICT
EMERGENCY AND ANNUAL HEALTH HISTORY INFORMATION
________________________________________________________________________________________________________________________________
Student’s Name _________________________________________________________________ Birth Date: ___________________________
Allergies to medication: _________________________________________________________________________________________________
Last
First
Middle
Medication
taken at homeHomeroom
or school: ______________________
________________________________________________________________________________________
Grade ___________
Teacher ________________________________________________________
Has
your______________________________________
child during the past year had an illness, injuries, operations
or special medical care? ______________________________________________
Address
City _________________
Zip ____________ Home Phone __________________
________________________________________________________________________________________________________________________________
Relationship and name of person with whom student resides: _____________________________________________________________________
I/We
authorize
the Elmira
City School District to act as temporary guardian to obtain medical or surgical care necessary for _____________________________,
List other
children
in the home:
who
that I cannot
NAMEis my son/daughter, in the eventAGE
SEXbe contacted.
BIRTH DATE
NAME
AGE
SEX
BIRTH DATE
_________________________________________________
________________________________________________
I/We
grant permission to hospital, hospital physician, family physician, pediatrician or whomever
he may designate to care for this patient in _________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Hospital,
by Doctor ___________________________________.
Our insurance company is: ______________________________________________________________________________________________
To Parent or Guardian: In case of an accident, sudden illness or emergency school closing, please furnish the following information:
Our
insurance numbers: ________________________________________________________________________________________________
NAME
PLACE OF EMPLOYMENT
CELL PHONE
BUSINESS TELEPHONE
FATHER:
_________________________________________________________________________________________________________________________
Date: _________________________________
Mother: _______________________________________________________
MOTHER:
________________________________________________________________________________________________________________________
Father: _______________________________________________________
List relatives or neighbors who will assume temporary care of your child for an illness or in an emergency situation:
NAME
ADDRESS
TELEPHONE
CELL PHONE
Guardian: _______________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
(Signature of Parents/Guardian)
Students in grades 2, 4, 7 and 10 and new entrants are mandated to have physicals. If the student does not present a record for a recent examination by the family
physician before October 31, he/she will be examined by the school physician/school nurse practitioner.
Examinations by the family physician: YES ______________
NO ______________
Date ______________
PLEASE COMPLETE REVERSE SIDE OF CARD
ELMIRA CITY SCHOOL DISTRICT
Health condition or conditions which may require special care: _____________________________________________________________________
595.01
EMERGENCY AND ANNUAL HEALTH HISTORY INFORMATION
________________________________________________________________________________________________________________________________
Student’s Name _________________________________________________________________ Birth Date: ___________________________
First
Middle
Allergies to medication:Last
_________________________________________________________________________________________________
Grade
___________
Homeroom
______________________
Teacher
________________________________________________________
Medication taken at home or school: ________________________________________________________________________________________
Address
City _________________
Zip ____________ Home Phone __________________
Has
your______________________________________
child during the past year had an illness, injuries, operations
or special medical care? ______________________________________________
Relationship and name of person with whom student resides: _____________________________________________________________________
________________________________________________________________________________________________________________________________
List other
children
in the home:
I/We
authorize
the Elmira
City School District to act as temporary guardian to obtain medical or surgical care necessary for _____________________________,
NAME
SEXbe contacted.
BIRTH DATE
NAME
AGE
SEX
BIRTH DATE
who is my son/daughter, in the eventAGE
that I cannot
_________________________________________________
________________________________________________
_________________________________________________
_________________________________________________
I/We
grant permission to hospital, hospital physician, family physician, pediatrician or whomever
he may designate to care for this patient in _________________
_________________________________________________
_________________________________________________
Hospital, by Doctor ___________________________________.
To Parent
or Guardian:
of an accident, sudden illness or emergency school closing, please furnish the following information:
Our
insurance
companyInis:case
______________________________________________________________________________________________
NAME
PLACE OF EMPLOYMENT
CELL PHONE
BUSINESS TELEPHONE
Our
insurance numbers: ________________________________________________________________________________________________
FATHER:
_________________________________________________________________________________________________________________________
MOTHER:
Date:
_________________________________
Mother: _______________________________________________________
________________________________________________________________________________________________________________________
Father:
List relatives or neighbors who will assume temporary care of your child
for an_______________________________________________________
illness or in an emergency situation:
NAME
ADDRESS
TELEPHONE
CELL PHONE
________________________________________________________________________________________________________________________________
Guardian: _______________________________________________________
________________________________________________________________________________________________________________________________
595.01
(Signature of Parents/Guardian)
Students in grades 2, 4, 7 and 10 and new entrants are mandated to have physicals. If the student does not present a record for a recent examination by the family
physician before October 31, he/she will be examined by the school physician/school nurse practitioner.
Examinations by the family physician: YES ______________
NO ______________
Date ______________