Student Medical Form

  • Medical Information For:

  • Physician Information

  • Dentist Information

  • Insurance Information

  • (Responding medical unit will make final determination as to the appropriate facility for the injury.)
  • Explain, in detail, any health considerations that may affect this child while at school (i.e., chronic conditions, previous surgeries, etc).
  • Please note: School based emergency medications do not leave this school for field trips or after school activities. The parents have the responsibility of making arrangements with his/her child's teacher or after school personnel supervising your child in providing emergency medication, from home, for each field trip or after school activity.
    If yes, you must provide the school's clinic with a signed consent form.
  • (Please detail any important allergies including insect bites/stings, foods, etc.)
    (If yes, you must provide the school's clinic with a signed consent form which is available at the lower school clinic)
  • School Health Service Consent

    Consent given for my student to participate in the School Health Services Program. This means my student will receive emergency care in school, if needed, and health appraisals at school, including screenings such as vision, pediculosis, scoliosis, and hearing and growth development. I will notify the school of any changes of this information in writing and submit it to the clinic personnel.*
    Consent given in case of an accident or illness where treatment is not needed, but where mys tudent is unable to remain at school, I request the school contact me. If I am unable to be reached, I request that one of the emergency contact persons listed in my Ren-Web Family Profile be contacted to care for my student until I can be reached. I will notify the school of any change of this information in writing and submit it to the clinic personnel.*
    In the event of a serious accident or illness, I request the school contact me at the numbers listed in my Ren-Web Family Profile. If the school is unable to reach me, I hereby authorize the school (noted by my initials) to contact the physician or dentist indicated and to follow his/her instructions. If it is impossible to contact the physician or dentist or if no physician or dentist's name has been provided above, the school may make whatever arrangements are necessary to provide emergency care and treatment for my student. I will notify the school of any changes in writing and submit it to the clinic personnel.*
    In the event of a life threatening accident or illness, I understand that the school may contact the 911 emergency medical systems immediately. My selection indicates my agreement to be financially responsible for my student's care and treatment.*
    In order to expedite care of my student, my selection hereby give my permission for the responding emergency team to immediately initiate treatment and transport of my student to the preferred or appropriate medical facility, according to what they deem is indicated by the nature or extent of the injuries. I agree to be financially responsible for my student's treatment and transport. I will notify the school of any changes in writing and submit it to the clinic personnel.*
    Consent authorizing any representative of the school, in whose care my student has been entrusted, to present my student to an approved medical treatment center, and do consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to my student under the general practitioner, surgeon or dentist licensed to practice in any state in the United States. I agree to be financially responsible for my student's treatment. I will notify the school of any changes in writing and submit it to the clinic personnel.*
  • I do hereby state that I am the legal parent or guardian of this student. I have completed the above medical information and have indicated my preferences for my student's treatment. Signed: *

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