Frederica academy

Frederica Academy
Student Health Information and Consent for Treatment at School and School Events
Last Name: ________________________________First Name: ___________________________________ Middle Name: ___________________________________Goes By: _________________________________ Date of Birth______________________ Gender_____ Grade ________ for 20___/20___ school year Name and Location of last school attended: _________________________________________________ Contact Information

Name of Doctor: _____________________________________________Phone number: _______________
We always attempt to contact Parents first. Please list 2 Emergency Contacts other than parents. These
persons are authorized to pick your child up from school.
Name: ___________________Relationship: __________H____________W_____________C_____________
Name: ___________________Relationship: __________H____________W_____________C_____________
Insurance Information

Insurance Company Name: __________________________________Phone:________________________
Name of Subscriber: _____________________________________ID number: _______________________
Group number: ____________________________
Health History
Allergies: Drug:_____________________Food:____________________________Other: ______________
Typical symptoms of allergic reaction: ______________________________________________________
Neurological, Cardiovascular, Respiratory, Kidney, Gastrointestinal, or Orthopedic problems:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Surgeries:
________________________________________________________________________________________
Prescription Medication--- Name, dose, frequency, purpose:
________________________________________________________________________________________
________________________________________________________________________________________
Other medical or psychological information we should know:
________________________________________________________________________________________
Please return this form to the School Nurse. Frederica Academy * 200 Murray Way Saint Simons Island GA * 31522 * Phone 638 9981 * Fax 638 1442 * School Nurse phone ext. 492 Frederica Academy
Consent for Treatment
2013/2014 School Year
Student Name: First_________________________ Middle ________________________ Last ____________________________

Parent/Guardian Health Consents: Please read and sign below.

 I confirm that the information on this form is current and complete as amended above or on back.  I authorize the school nurse to contact my child’s physician for further medical information if  I authorize that the following over-the-counter medications may be given at school or during school activities (Cross out items you do not want child to receive): Tums, Antibiotic Ointment, Benadryl Spray for itching, Benadryl/Claritin Antihistamine for allergic reactions, Hydrocortisone Cream,  I understand that prescription medications are to be kept and dispensed by the school nurse, designated teacher, or coach as outlined in the Frederica Academy Prescription Medication Policy.  I authorize first aid and emergency medical treatment while my child is under the supervision of Frederica Academy. In case of serious illness or injury, I authorize school personnel to call 911 for transport to the nearest hospital and treatment by hospital emergency staff.
Parent/Guardian Signature: _______________________________________________Date_____________________________

Please return this form to the School Nurse. Frederica Academy * 200 Murray Way Saint Simons Island GA * 31522 * Phone 638 9981 * Fax 638 1442 * School Nurse phone ext. 492

Source: http://www.fredericaacademy.org/Customized/uploads/School%20Life/Health/Student%20Health%20Information%20and%20Consent%20Form.pdf