Bolno or EoucarpHMafthew R. Clegg, President

. Tracie H. West. Vice-PresidentCharles SmithMelanie D. ChamblessWilliam T. Hutto, Jr.

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4 n r * t t h' G n l {- K [

; \ t r lCirv Schrx:ls

AovlHlstRnrroHDr. Karen T. DeLano, Superintendent

Dr. Dennis Veronese, Assistant SuperintendentCristen P. Herring, Assistant Superintendent

2014-2015 School Year - Renewal Registration

Dear Parent or Guardian:The attached State of Alabama Health Assessment Record is required for student registration. Please complete andsubmitthe form to the school nurse before Monday. May 72. 2074.

Page 1

Page 2

Complete each section, including checking all applicable boxes under Authorizations.

If your child does not have a diagnosed chronic condition and will not require medicationadministration or a special health service procedure while in school:

,/ Check the box at the top of the page; andr' Sign your name atthe bottom of the page.

If your child does have a diagnosed chronic health condition andf or does require medicationadministration or a special health service procedure while in school:

./ Complete the page; and,/ Sign your name at the bottom of the page; and,/ Inform the school nurse; and,/ Schedule a conference with the school nurse,

School Grade

State of Alabama Department of EducationHealth Assessment Record

School Year: 2014 - 2015

To Parent or Guardian:This form is required as part of student registration for the upcoming 2014-2014 School Year. The information isessential for the school nurse to meet the health needs of your child.

This information will be kept strictlv confidential.

Place where your child receives regularhealth care:n Health DepartmentI HospitalCl inic! Community Health Centern Private Doctor/HMOn othern Uo regular place

Physician's Name:

Address:

Tel:

Return to the School Nurse by Mondav, Mav 12.

Part l- Health lnformationPlace where your child receives regulardental care:n Healtn Departmentn HospitalCl inicn Community Health Center! Private Doctor/HMOn otnern no reguAr ptace

Dentist's Name:

Type of Insuranceyour chi ld has:n Medicaidn ruo insurance! Private InsuranceI ALLKIDSn other:

Address:

Tel :

c Each Section. PLEASE PRINT.Name of Student (Last, First, Middle) Social Security or Assigned No. Birth Date Sex

Address (Street) Race/Ethnicity LJ Pacific lslander! Indian! Multi-Race (2 or more)E Not specified

E White! BlackE Asian

City and Zip Code

Home Telephone Number I Cel l Phone Number School Grade

Name of ParenVGuardian (Last, First, Middle)

Transportation

E Bus Rider n Car Rider n Special Needs Bus E AfterSchool Program

Authorizations: (You must initial in the appropriate/applicable space for each statement.)

I authorize the school nurse, the registered nurse (RN) or l icensed practical nurse (LPN), to talk with thephysician(s) should a question come up about my child's medical conditions.I do NOT authorize the school nurse, the RN or LPN, to talk with the physician(s) should a question comeup about my child's medical conditions.

I authorize for my child to participate in all school health screenings (vision, scoliosis, BMl, hearing).

I authorize the yearly review of my child's Certif icate of lmmunization (Blue Slip) by the local Public HealthDepartment.

OVER - Please sign at the bottom of page 2+OVER

YES

[]

nEn

NO

tlrET

School: Grade:

State of Alabama Department of EducationHealth Assessment Record

School Year: 2014 - 2015

PART ll - Student's Medical His Check those thatNO KNOWN HEALTH PROBLEMS - Godi to the bottom of theAttention Deficit Disorder (ADD) OR Requires medication?Attention Deficit DisorderADHD To be while at school? *Allergies: Please specify:

fl Hives/rash? EBreathing difficulty? ! Epipen?. n Other? (List:

and provide parent/guardian

D Hives/rash? flBreathing difficulty? ! Epipen?. E Other? (List:n Foodn lnsectstr Medicationn Seasonal

! Hives/rash? EBreathing difficulty? ! Epipen?" E other? (List:D Hives/rash? EBreathing difficulty? ! Epipen?. n Other? (List:

He/She uses an inhaler at school?

Seizure Disorder: f'

accommodations at school due to the conditions checked above?

Other

Bleeding Problems:l ia, Von

Cancer/Leukemia:Cerebral

Diabetes:

E Hives/rash? n Epipen?.I Other? (List:He/She uses an inhaler at home?*

Glucagon order?*Managed with diet?

Requires medical attention? Explain:nosebleeds

Braces? - or list other:Monitors blood glucose while at school?Requires lnsulin at school?*Type 1 Diabetic

Tvpe 2 Diabetic n InsulinEmotional/Behaviora

Genetic Disorder:Genito-Uri Disorder:Headaches:Hearing Problems: Right Ear Hearing loss? Hearing aid? Tubes?

n Left Ear n Hearing loss? tr Hearing aid? n Tubes?Cochlear

Heart Condition: Explain: Activity restrictions? Medications taken at home only? Requires medication at school?*nston Bfood Pressure): Takes medication?*

Juvenile Arthritis/Bone-Joint Problems:Kidnev Problems:Scol iosis: No Treatment /Observation Wears Brace

Sickle Cel lAnemia: Sickle Gel lTrai t :Bifida:

Special Diet: E

Other Medical Gonditions: lnclude 9417 medications taken at home only.

CatheterVentilator

Part l l l - MedicalGastric TubeCPAP/BI-PAP

nUProcedures Required (ctrecxNebulizer Treatments Oxygen Supplement

Braces Wheelchair

Signature of parent(s) or guardian:Signature of school nurse:

Required SignaturesWalker

Tracheostomy