* INFORMATION TO BE COMPLETED BY PARENT/GUARDIAN *
Student Information
Legal Last Name:
Legal First Name:
Legal Middle Name:
«Mi
SSN # (Last 6 Digits)
____ - _______
Gender:
Date of Birth:
Phone #:
Ethnicity:
Street Address: (Must include a street number and name)
City:
State:
Zip:
County/LEA:
Mailing Address:
Resides With:
Custody Forms on File at School
 No
 Yes
Relationship:
Parent/Guardian Information
Full Name of Mother/Guardian:
Home Phone:
Cell Phone:
Email Address:
Address:
Employer:
Work Phone:
Full Name of Father/Guardian:
Home Phone:
Cell Phone:
Email Address:
Address:
Employer:
Work Phone:
Emergency Contact Information
Name:
Phone:
Work Phone:
Cell Phone:
Name:
Phone:
Work Phone:
Cell Phone:
Name:
Phone:
Work Phone:
Cell Phone:
Relationship:
Other Contact No:
Relationship:
Other Contact No:
Relationship:
Other Contact No:
Activities: I give my permission for my child to participate in the following: *Please Initial*
Photographed, Interviewed and/or
Videotaped for School/DPI Use &
Publications, News Publications/TV
Stations
______ Recreational Activities/Sports
______ Swimming
______ Yes
______ Off-Campus Activities
______ No
*** SCHOOL USE ONLY ***
UID #
Revised June 2014
School:
Student Type
* INFORMATION TO BE COMPLETED BY PARENT/GUARDIAN *
Student Name:
List of Authorized Person(s) who may pick up or take student off school grounds.
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Name:
Phone:
Relationship:
Visitation Restrictions (if any)
Health Information
Amplification: Hearing Aid □ Left □ Right □ Cochlear
Implant
Does Student have glasses or contacts?
No
□ Yes
□
Please list low vision devices (if any): ________________________________________________________
Other: □ Wheel Chair □ Leg Braces
□ Communication System □ Other
Special Dietary Plan/Needs:
Specific Fears/Phobias:
Allergies:
Special Alerts/Information for Staff:
Parent/Guardian Signature
Printed Name Parent / Guardian ____________________________________________________
Date: _______________
Signature Parent/Guardian _____________________________________________________________ Date: _______________
July 2014
Guidance for Completing the Medical Statement for Students with
Special Nutritional Needs for School Meals
Parent/Guardian:
The Medical Statement for Students with Special Nutritional Needs for School Meals helps schools provide meal
modifications for students who require them. Completion of all items will allow your child’s school to create a plan
with you for providing safe, appropriate meals to your child while at school.
Your participation in this process is very important. The sooner you provide this signed and completed form to your
child’s school, the sooner the Child Nutrition Program or school staff can prepare the food your child requires. Your
signature is required for your school to take action on the medical statement. The school staff cannot change food
textures, make food substitutions, or alter your child’s diet at school without all the information filled in on this form.
Please follow the steps below to get started:
1) Complete all items of PART A of the Medical Statement.
2) Take the Medical Statement to your child’s pediatrician or family doctor and have him/her complete PART B.
3) Return the properly signed Medical Statement to your child’s teacher, principal, nurse, Special Education
case manager, or Section 504 case manager, Child Nutrition Administrator, or the school staff person who
gave you the blank form.
4) Ask the school when a team, including you and the school system’s Child Nutrition Administrator, will meet
to consider the information provided on the form. You may invite people from the community who are
knowledgeable about your child’s feeding and nutrition issues to the meeting. These would be people who
could help school staff design a school mealtime plan for your child, like your child’s pediatrician, nurse,
speech-language pathologist, occupational therapist, registered dietitian or personal care aide.
Physicians and Medical Authorities:
This form helps schools provide meal modifications for students who require them. Completion of all items will
streamline efficient care of the student.
The school cannot change food textures, make food substitutions, or alter a student’s diet at school without a proper
statement from you. Meal modifications are implemented based on medical assessment and treatment planning
and must be ordered by a licensed physician or recognized medical authority.
Please consider the following as you complete PART B of the Medical Statement:
1) Complete all items of PART B. (Note: A licensed physician’s signature is required for students with a
disability. For students without a disability, a licensed physician or recognized medical authority must sign
the form. Recognized medical authorities include physicians, physician assistants, and nurse practitioners.)
2) Be as specific as possible about the nature of the child’s disability and life activities that the disability limits. In
the case of food allergy, please indicate if the student’s condition is a food intolerance, an allergy that would
affect performance and participation at school (e.g., severe rash, swelling, and discomfort), or a life-threatening
allergy (e.g., anaphylactic shock).
3) If your assessment of the child does not yield sufficient data to make a determination about food substitutions,
consistency modifications, or other dietary restrictions, please refer the child/family to the appropriate feeding,
nutrition, or allergy specialists for completion of the Medical Statement. Schools do not routinely have
instrumentation and/or staff trained for a comprehensive nutrition and feeding assessment and must partner
with community providers to meet a student’s special feeding and nutrition needs.
4) Attach any previous and/or existing feeding/nutrition evaluations, care plans, or other pertinent documentation
housed in the student’s medical records to the Medical Statement for parent/guardian delivery to the school.
5) Consider being available to consult with the child’s school team as it implements the feeding/nutrition care
plan.
July 2014
Medical Statement for Students with Special Nutritional Needs for School Meals
When completed fully, this form gives schools the information required by the U.S. Department of Agriculture (USDA), U.S. Office for Civil
Rights (OCR), and U.S. Office of Special Education and Rehabilitative Services (OSERS) for meal modifications at school. See “Guidance
for Completing Medical Statement for Students with Special Nutritional Needs for School Meals” for help in completing this form.
PART A (To be completed by Parent/Guardian)
Name of Student: (Last)
Date of Birth
(First)
Student ID #
(Middle) ____
School
Grade ______
Will student eat breakfast provided
by the school cafeteria?
Will student eat lunch provided
by the school cafeteria?
Will the student eat a snack provided
by the After School Snack Program?
 Yes  No
 Yes  No
 Yes
 No
Printed Name of Parent/Guardian: ___________________________________________________________
Mailing Address: _________________________
Phone number(s): ____________________
(Work)
City: ________________
______________________
(Home)
State/Zip: __________
_____________________
(Cell)
Email Address: ______________________
What concerns do you have about your student’s nutritional needs at school?
What concerns to you have about your student’s ability to safely participate in mealtime at school?
Does the student have an identified disability and an Individualized Education Program (IEP) or 504 Plan?
 Yes  No
If Yes and you have concerns about nutritional needs, have a licensed physician complete Part B,
page 2, of this form and sign it. Return completed form to
_____________________________________________.
If No and you have concerns about nutritional needs, have a licensed physician or recognized medical
authority complete Part B, page 2, of this form and sign it.
Return completed form to _____________________________________________.
NOTE: Special dietary needs for students without an IEP or 504 Plan are accommodated at the discretion of
the Child Nutrition Administrator and policies of the school district.
Parental/Guardian Consent: I agree to allow my child's health care provider and school personnel to discuss
information on this form.
Parent/Guardian Signature: _______________________________________
July 2014
Date:_____________
PART B (To be completed by Licensed Physician)
Check major life activities affected:
Student Diagnosis or condition:
 Walking
 Seeing
 Hearing
 Speaking
 Breathing  Working
 Learning
 Other
_____________ Performing manual tasks  Caring for self
(including eating)
Specify any dietary restrictions or special diet instructions for school meals:
Designate consistency requirements for food:
 Clear Liquid
 Pureed
 Full Liquid
 Mechanical Soft
 Blenderized liquid
 No change needed
Designate consistency requirement for liquids:
 Thin
 Spoon-thick
 Nectar-like
 No change needed
 Honey-like
N
List any foods causing food intolerance that should be avoided: ___________________________
List any foods causing food allergies that should be avoided: _____________________________
If student has life threatening allergies*, check appropriate box(es):  ingestion  contact  inhalation
* Students with life threatening food allergies must have an emergency action plan in place at school.
For any special diet, list specific foods to be omitted and substitutions; you may attach a separate care plan.
a. Foods To Be Omitted
b. Recommended Substitutions
Indicate any other comments about the child’s eating or feeding patterns, including tube feeding if applicable:
If a nutritional/feeding care plan has not been developed prior to completion of this form an additional
assessment is required, please refer student for feeding and nutritional assessment in your community.
School-based personnel do not routinely have instrumentation and/or training for a comprehensive nutrition
and feeding assessment.
Signature of Physician/Medical Authority*
Printed Name
Phone Number
Date
* A licensed physician’s signature is required for students with a disability. For students without a disability,
a licensed physician or recognized medical authority must sign the form.
PART C (To be completed by Child Nutrition Services)
Child Nutrition Services Notes:
CN Administrator Signature: _________________________________
Date: ______________________
“In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national
origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington,
D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.”
July 2014
GOVERNOR MOREHEAD SCHOOL FOR THE BLIND
STUDENT HEALTH CENTER
PERMISSION FOR PSYCHIATRIC CARE AND AUTHORIZATION TO PROVIDE PSYCHIATRIC ATTENTION
Student’s Name: _________________________________
Date of Birth: ______________
Consent is hereby given for my child to:
 Be evaluated and treated by the school Child Psychiatrist and to receive medications, treatments, and lab work as
ordered.

Be seen by the school Psychiatrist for evaluation, consultation, and counseling. To receive medications prescribed by the
school Psychiatrist.

Be referred by the Child Psychiatrist, counselors, or nurse to the local mental health agency for consultation, evaluation,
individual/group therapy and/or individual counseling.

Be referred by the Child Psychiatrist for medical evaluation.

Receive prescribed medications that I send from home. These medications must be sent in the original containers and
properly labeled. I will notify nursing staff by letter or telephone for the reason for the medication. I give my permission
for the Student Health Center staff to contact the prescribing physician to obtain orders to administer this medication.

Receive prescribed medications when my child is away from the Student Health Center on a field trip or activity. I give
consent for designated trained staff members to administer the medication to my child as prepared by the Student Health
Center staff/pharmacy.

Be referred by the Child Psychiatrist/treatment team for evaluation and counseling by the school’s behavioral specialist
and the school’s counselors.
Be transported by a GMS employee to and from a clinic, physician’s office, Mental Health Agency, or hospital as referred
by the Child Psychiatrist/counselor/nursing staff.



Receive any emergency psychiatric care when necessary whether the incident occurs at GMS, while participating in a
school sponsored field trip/athletic event away from the school, during transportation of my child to and from that event, or
during transportation of my child to and from home. I hereby authorize the Governor Morehead School for the Blind to
locate the necessary psychiatric attention and to sign on my behalf any required papers authorizing treatment. I am
responsible for any/all medical costs incurred for emergency treatment of my child. I understand attempts will be
made to reach me for all emergency/psychiatric care involving my child. I will provide the Student Health Center with
current medical/psychiatric history to include medication, food, and/or environmental allergies and past/current
medical/psychiatric information that are necessary for providing appropriate care to my child. I give permission for the
treating facility to release treatment records to the Student Health Center following emergency psychiatric treatment.
Your child’s confidential medical/psychiatric record will be maintained at the Student Health Center. The Student Health
Center staff may use or disclose your child’s information to any referred physician, clinic, or hospital in order to provide,
coordinate, or manage his/her medical/psychiatric care. This information may include allergies, medical problems
(current and past), and psychiatric history summary, current information (i.e. behavior/treatment plan), medications history
and regimens. This information may be provided to appropriate GMS staff members working directly with my child on an
one to one “need to know” basis and only the minimum information needed to assist with providing my child
appropriate care will be released. Information to be shared with other staff would include allergies, potential side effects
of medications and care for medical conditions, physical disabilities and limitations, psychiatric history summary, current
treatment plan and behavioral plan so as to assure appropriate care is provided to my child.
I hereby give consent for my child to receive the above services. I have read and understand this permission form. This
permission form will be effective from August 17, 2014 to July 10, 2015.
Parent/Guardian Name: ______________________________
(Print)
_______________
Date
Parent/Guardian Name: ______________________________
(Signature)
_______________
Date
Signature of Nurse Reviewing: ___________________________
Date________________
Revised June 2014
Immunization Record Form 2014 – 2015
Immunization Record (Print in black ink) To be completed by Health Care Professional
Last Name
First Name
Middle Name
DOB
SS#
____/___/____
Section A: Required Immunizations:
#1 Date
#2 Date
#3 Date
#4 Date
#5 Date
DTP or Td
____/___/____ ____/___/____ ____/___/____ ____/___/____
____/___/____
Td Booster
____/___/____ ____/___/____ ____/___/____ ____/___/____
____/___/____
Polio
____/___/____ ____/___/____ ____/___/____ ____/___/____
____/___/____
MMR
____/___/____ ____/___/____ ____/___/____ ____/___/____
____/___/____
MR
____/___/____ ____/___/____ ____/___/____ ____/___/____
____/___/____
Disease Date NOT
Titer Date/Result**
Mumps
____/___/____ ____/___/____ ____/___/____
Rubella
____/___/____ ____/___/____ ____/___/____
TB Test (PPD)
**requirement for
Date Read
____/___/____
Accepted
Disease Date NOT
Accepted
MM Induration
Titer Date/Result**
Comments:
new students
Chest X-ray (for PPD)
Treatment (If Applicable)
Therapy Regime:
Date ____/___/____
Date Initiated:
Result:
Date Terminated:
Section A: Required Immunizations: The following immunizations are recommended for all students and may be required
in specific circumstances.
#1 Date
#2 Date
#3 Date
Titer Date/Result
Hepatitis B Series
____/___/____ ____/___/____ ____/___/____
Varicella-2 does or titer
____/___/____ ____/___/____ ____/___/____
Section C: Optional Immunizations: Consult with your private physician regarding these vaccines.
#1 Date
#2 Date
#3 Date
Titer Date/Result
HIB
____/___/____ ____/___/____ ____/___/____
Pneumococcal
____/___/____ ____/___/____ ____/___/____
Meningococcal
____/___/____ ____/___/____ ____/___/____
Hepatitis A
____/___/____ ____/___/____ ____/___/____
HPV (Human Papilloma Virus):
____/___/____ ____/___/____ ____/___/____
Other:
____/___/____ ____/___/____ ____/___/____
Signature or Clinic Stamp REQUIRED
______________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner
______________________________________________________
Print Name of Physician/Physician Assistant/Nurse Practitioner
______________________________________________________
Office Address
Revised July 2014
________________________
Date
________________________
Area Code/Phone Number
___________________________
City/State/Zip Code
Parent’s Consent for Medicaid
Information to be completed by Parent/Guardian for the Education Services f/t Deaf & Blind Medicaid Billing
Program. The disclosure form indicates by your signature that you are aware your child’s confidential
educational and medical information will be disclosed to Medicaid. GMS is allowed by current laws to file for
Medicaid reimbursement if your child is eligible for Medicaid and receives services such as: Nursing Services,
Physical Therapy, Occupational Therapy and Speech Therapy.
Student’s Name: ______________________
Student’s Social Security Number______________________
Student’s Medicaid ID Number______________________
Student’s Birth Date: _______________
Student’s Address:______________
Street
Student’s Sex: _____________
City/State
______________________
Zip Code
Student’s Phone Number: ______________________
Name School Attends: The Governor Morehead School f/t Blind
USD#_______________
Parent’s/Guardian’s Name_________________________________________________________
Name of Student’s Doctor__________________________________________________________
Doctor’s Address_________________________________________________________________
Street
City/State
Zip Code
Doctor’s Phone Number (____) ___________
Please allow the school to copy or send a copy of your child’s Medicaid Card with this form. This form needs
your signature and it will be placed in your child’s educational file.
Release of Information Authorization
My signature below authorizes the school district indicated above and the North Carolina State Department of
Education to share with the North Carolina Medicaid Agency my child’s identification and IEP information. This
information is to be used to allow the school district to claim Medicaid funds for health related services
delivered to my child.
I am aware that the Local Education Agency is responsible for providing special education and related services
as listed on my child’s IEP at no cost to me. My signature on this form will assist my school district in receiving
funds to help pay for special education services. I have signed and understand this information.
Parent’s/Guardian’s Name ________________________________
(Printed)
___________________
Date
Parent’s/Guardian’s Name ________________________________
(Signature)
___________________
Date
Revised July 2014
Physical Examination Form 2014-2015
This form is to be completed by a licensed physician, physician’s assistant or nurse practitioner. A physical examination
current within the previous twelve months is required for enrollment. A physical examination is recommended every two
years thereafter. Our Middle School and High School Student Athletes are required to have a Sports Physical
within the previous twelve months in order to participate in interscholastic sports.
Student Name:
DOB:
VITAL SIGNS/LABS/ALLERGIES:
HT:
WT:
Temp:
Pulse:
U/A:
Blood:
Protein:
Glucose:
Date of Physical: ____/___/____
Resp:
Sp. Gravity:
BP:
HGB/HCT:
PH:
Leukocytes:
PHYSICAL EXAMINATION:
Check if Normal:
Describe Abnormalities:
Eyes
Ears/Nose/Throat
Head/Neck
Chest/Heart/Lungs
Abdomen
Genitalia/Hernia/Testes (Boys)
Menses/Breast Exam (Girls if age appropriate)
Skin
Extremities
Spine
Neurological
Please summarize history or findings and/or elaborate on above if necessary:
____________________________________________________________________________
____________________________________________________________________________
PHYSICIAN RESTRICTIONS: Students are required to participate in curriculum required physical education and are
expected to meet athletic team responsibilities and commitments unless restricted by written physician order.
Physical Activity: Please list specific restriction and duration of restriction:
Special Dietary Restriction: Please list specific diet. A written physician’s order is required for dietary supplements, MVI and
non-traditional diets. Start and stop dates and follow up dates for reassessment must be provided
I hereby certify that I have examined the student herein described and have reviewed this student’s health history. I certify that this
student is able to participate in all academic, athletic and residential activities except as noted above.
________________________________
Signature of Physician
Revised July 2014
_________________
Phone
________________
Date
SPECIAL HEALTH CARE PERMISSION
(The Health Education permission is effective for the entire school year and terminates on the last day of
school.)
Health Education Permission:
Student Health Services and health care professionals from the community conduct health sessions. These
speakers include health educators, local physicians, nurses and other health care professionals. Each health
care professional has specific expertise on the subject presented. These speakers conduct similar sessions in
the Wake County Public Schools.
All sex education curriculums are abstinence based. All sessions are general session lasting one hour and do
not include individual counseling. These sessions are being conducted at the request of the students.
Students attend on a voluntary basis. Students are separated into same sex classes.
My Child, ____________________________ has my permission to participate on a voluntary basis in
all Health Sessions listed below.
My child, _____________________________ does not have my permission to participate on a
voluntary basis in all the Health Sessions listed below.
My child, ____________________________ has my permission to participate in all Health Sessions
with the exception of the following: Please list all discussions in which you do not want your student to
participate.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
List of Subjects: Dating, Date Rape/Sexual Assault Prevention, STDs, HIV/Aids Prevention, Tobacco Use
Prevention, Substance Abuse Prevention, Abstinence Based Family Planning, Human Reproductive System,
Life Cycle from Pregnancy to Birth, Personal Hygiene Tips, Breast Self Exam, Testicular Exam for boys, Pelvic
Exam/Pap Smear for girls, Mammogram, Hernia Exam for boys, Nutrition, Eating Disorders, Acne/pimples, Self
Esteem, Healthy Weight Loss, Healthy Weight Training.
Please list any other subjects you would like to see discussed during our sessions.
__________________________________________________________________________
__________________________________________________________________________
Parent / Guardian Name: _______________________________
(Print)
_____________________
Date
Parent / Guardian Name: ______________________________
(Signature)
_____________________
Date
Revised July 2014
Consent for Medication Administration
by Non-Medical Personnel
Designated non-medical school personnel will be trained annually to administer medication to
students when a nurse in unavailable. Medications given by non-medical personnel will include
prescription medications and non-prescription medications on field trips and weekend activities.
No medications will be given without prior authorization from Student Health Center nursing
staff. There must be a current physician order on file in order for any prescription medications to be
administered by Health Center staff, or non- medical personnel. If the routine prescription
medications that you would like administered on an after-school or off-campus activity are not usually
given during school hours, please make arrangements with the Student Health Center prior to the
date of the activity.
Approval for over the counter medication will be given for the symptoms a student presents. The
medication given will be included in the standing orders that are signed by our staff physician. A
student may request to come to the Student Health Center at any time.
Over-the-Counter Medications given by Non-Medical Personnel
Maalox
Ibuprofen or Tylenol
Cepacol Throat Lozenges
I hereby authorize Student Health Center staff to delegate administration of prescription and over-thecounter medications and prescription medications for field trips to my child by non-medical personnel;
Parent / Guardian Signature _______________________________________
I do not authorize Student Health Center staff to delegate administration of over-the-counter
medications by non-medical personnel; I do however authorize non-medical personnel to administer
to my child prescription and over-the-counter medications while my child is on a school sponsored
field trip; I understand that my child will have to come to the Student Health Center for all medications
while on campus.
Parent / Guardian Signature _______________________________________
Revised July 2014
Governor Morehead School for the Blind
Student Health Center
2014-2015 Medical History Update
Student’s Name: ______________________
Date of Birth: _____________
Parent/Guardian please complete the following information related to your child’s health and medical history.
1.
2.
3.
4.
5.
Has your child been seen by a doctor in the past 6 months?
Yes
No

If yes, why was he/she seen and what was the approximate date?
Has your child been seen by the dentist in the past 6 months?
Yes
No
Has your child been seen by an eye doctor in the past year?
Yes
No
Has your child ever had any type of surgery?
Yes
No
Does your child have any problems with any of the items listed below? If yes please explain.
Ever had an eye injury
Visual problems
Seasonal
allergies
1.
Frequent sinus infections
Ever had a head injury
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Frequent ear infections
Ever had tubes in ears
Frequent headaches
Frequent sore throats
Diabetes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Complaints of chest pain
Ever had any heart problems
Heart murmur
Difficulty breathing
Chronic cough
Asthma
Does he/she use inhaler
Frequent chest colds
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Ever had any bleeding problems
Anemia
Frequent stomach aches
Any problems swallowing
Frequent indigestion
Diarrhea/Constipation
Problems controlling bowels
Problems controlling bladder
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Permitted to play sports
Permitted to participate in PE
Ever had any back injury
Any serious joint/ligament injury
Complaints of joint pain
Does he/she exercise regularly
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Ever had any broken bones
Ever had any pulled muscles
Complaints of bone pain
Frequent ankle sprains
Ever had any orthopedic surgery
Does he/she lift weights
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Any problems sleeping
Bedwetting
Problems paying attention
Acting anxious, panicky
Physically aggressive
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Nightmares
Frequent temper tantrums
Acting sad or depressed
Ever tried to hurt or kill himself
Problems managing anger
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Please explain below any YES answers to your responses above :
2012-2013 Medical History Update (cont.)
Revised July 2014
6. Does your child take any medications regularly?
Yes
If yes, please list them below and explain why he/she takes the medication:
No
7. Is your child allergic to any medication?
Yes
No
If yes, please list the name of the medication and what type of reaction the medication causes (i.e. rashes, trouble breathing,)
8. Is your child allergic to any foods?
Yes
No
If yes, please list the name of the food and describe what type of reaction the food causes
9. Is your child allergic to bee stings or other insect stings?
Yes
If yes please describe the reaction that occurs and what treatment you use
No
This confidential information is kept in the Student Health Center. If there are any changes in your child’s medical Information,
please keep us updated.
Parent/Guardian Signature: _______________________________________________ Date: _______________
Reviewing Nurses’ Signature: ______________________________________________ Date: _______________
Revised July 2014
Student Health Center
Health Care Provider Information and Student Insurance
Health Care Provider Information
Student Personal Information:
Student Name:
Student SS#:
___/__/___
Age:
Date of Birth:
Date: ___/___/____
Sex:
Ethnicity:
Primary Care Physicians/Dentists/Other Physicians who serve your student:
(Note the school physician is not your student’s primary care MD)
Student’s Home Doctor:
Phone:
Student’s Home Dentist:
Phone:
Student’s ENT Doctor:
Phone:
Student’s Orthopedist:
Phone:
Student’s Neurologist:
Phone:
Student’s Psychiatrist:
Phone:
Other Specialist:
Phone:
Student Insurance Information
(Attach copies of all health insurance cards, prescription cards and Medicaid card)
Student’s Health Insurance Provider:
Group/Certificate#:
DOB
Name of Policyholder:
Relationship:
Student’s Prescription Plan Provider:
Group Certificate#
Name of Family’s Authorized Pharmacy:
Phone:
I certify that the information listed above is true to my knowledge. I agree to inform the nursing staff of any changes to the
above information. I authorize the school director, medical director and nursing director to release the above information to
any and all health care providers as well as to direct care staff members for the purposes of education, evaluation,
diagnostic testing and follow up in compliance with the Health Information Privacy Protection Act. I authorize the release of
any and all medical and health information to the Student Health Center medical director and nursing director from any of
the above named Physicians, dentists, health care providers and insurance companies in compliance with the Health
Information Privacy Protection Act (HIPPA)
Parent / Guardian Name _________________________________
(Print)
Parent / Guardian Name _________________________________
(Signature)
Revised July 2014
_________________
Date
_________________
Date
Emergency Consent Form - 2014-2015 School Year
As the parents/guardian of ______________________ a student at Governor Morehead School, I do hereby authorize
GMS to act as my representative in giving consent for acute/emergency medical, dental, ophthalmology and/or optometry
treatment as well as any psychiatric/psychological counseling necessary, during the school year. In case of an
emergency, prior to any major medical treatment, every effort will be made to contact me. As parent/guardian, I will
assume responsibility for all expenses involved in the treatment of my child not covered by the school or other insurance.
I assume responsibility for expenses incurred related to purchasing prescription medication for my child. GMS will not be
financially responsible for providing prescription medication to students. I will provide a valid insurance card to GMS to be
used for my student to obtain acute/emergency medical services and/or medication.
I authorize the release of any health care information from any health care facility or physician to the school physician or
the school nurse. I authorize the release of any and all health care information from the school physician or the school
nurse, which in their best judgment is necessary for the health and well-being of my student.
In the event of a medical catastrophic event (such as Bioterrorism or Pandemic Flu) I give permission for my child to
receive services such as antibiotics/antiviral agents or vaccines.
I authorize the Student Health Center staff and school physician to:
 Provide acute and routine health care services to my student.
 Provide vision, health and dental screenings as required or recommended by the Department of Public Instruction
and NCDHHS.
 Administer medications and treatments for my student as directed by the Student Health Center Physician.
 Transport my student to health care facilities such as WakeMed Hospital and Wake Radiology.
 Radiology for acute/emergency services deemed necessary by the school physician.
 Accept physician orders for medication, treatment regimens, and dosage adjustments to said physician order and
I understand that if discrepancies exist between my dosage request and the written physician’s order that the
nurse is obligated to administer medication as written on the physician’s order until a new order is obtained which
concurs with my dosage request.
I agree to:
 Provide physician’s orders signed by the prescribing physician, and all medications, treatments, special dietary
order/restrictions, alternative medication and therapy.
 Provide all medication in pharmacy labeled containers listing the name of the medication or treatment, the name
of the prescribing physician, current dosage schedule, the date of the prescription and the number of refills.
 Provide update emergency contact information to the nursing staff immediately when such information changes.
 Be financially responsible for payment of all health care bills generated in health care facilities and pharmacies
other than those stock health care supplies and the services provided by the nursing staff and school physician
within the confines of the Student Health Center.
I understand that:
 My student is required to participate in curriculum required physical education.
 The NC High School Athletic Association requires my student to have sports physical within the previous 12
months before being allowed to practice or play in any interscholastic team sport.
 This authorization shall be effective upon the first day of school and shall end upon the last day of school.
Your child’s confidential medical/psychiatric record will be maintained at the Student Health Center. The Student Health
Center staff may use or disclose your child’s information to any referred physician, clinic, or hospital in order to provide,
coordinate or manage his/her medical/psychiatric care. This information may include allergies, medical problems (current
and past), and psychiatric history summary, current information (i.e. behavior/ treatment plan), medications history and
regimens. This information may be provided to appropriate staff members working directly with my child on a one to one
‘need to know’ basis and only minimal information needed to assist with providing my child appropriate care will be
released. Information to be shared with other staff would include allergies, potential side effects of medications and care
for medical conditions, physical disabilities and limitations, psychiatric history summary, current treatment plan and
behavior plan so as to assure appropriate care is provided to my child.
Parent / Guardian Name _________________________________
(Signature)
Witness _________________________________
(Signature)
Revised July 2014
_________________
Date
_________________
Date
Student Health Center Medication Authorization Form
2014 - 2015
THIS PORTION TO BE COMPLETED BY A PHYSICIAN
Student’s Name:
Date of Birth:
Please write each medication name, strength (ex: 100md), dose (how many pills to be given), the route (by
mouth, apply to skin, rectally), and the times the medication is to be given while at home. Please use back for
additional medications.
Name of Medication
Strength
Dose
Route
Time to be
# of Refills
given
______________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner
________________________
Date
______________________________________________________
Print Name of Physician/Physician Assistant/Nurse Practitioner
________________________
Area Code/Phone Number
THIS PORTION TO BE COMPLETED BY PARENT/GUARDIAN
I, as the parent/legal guardian of the above named student, do hereby give permission for my child to receive
the following medication(s) regularly as prescribed by a licensed physician. I understand that:
 Medication is to be administered by GMS nursing staff or designated personnel, when prepared by the
pharmacy/nursing staff.
 The medication purpose, potential side effects/adverse reactions, and any precautions or special
directions regarding medication administration, have been explained to me by my child’s physician,
nursing staff, pharmacist, counselor, or medication information sheet.
 As the parent, I may (at any time), revoke permission to have the medication(s) administered.
This permission is valid for the school year 2014 – 2015
I have read and understand the above information.
Parent/Legal Guardian Signature:_______________________________ Date:_______________
- over -
Revised July 2014
Student Health Center Medication Authorization Form
2014 - 2015
THIS PORTION TO BE COMPLETED BY A PHYSICIAN
Additional Medications (if any)
Student’s Name:
Date of Birth:
Please write each medication name, strength (ex: 100md), dose (how many pills to be given), the route (by
mouth, apply to skin, rectally), and the times the medication is to be given while at home.
Name of Medication
Strength
Dose
Route
Time to
be given
# of Refills
______________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner
________________________
Date
______________________________________________________
Print Name of Physician/Physician Assistant/Nurse Practitioner
________________________
Area Code/Phone Number
Revised July 2014