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Child Health Information Nottingham School
Child's Name: _______________________________________ Date of Birth: ___________________ Grade: ___________
Please note that the information on this form is documented on your child’s school health record and
the school nurse will share this information with the appropriate school staff as needed.
1. Does your child have allergies
______No ______ Yes
(IF YES: What? Please check below and note treatment.)
2. Does your child take any medicine
on a regular, ongoing basis? ______ No ______ Yes
Name of Medication
Reason for Taking
Special Instructions for
3. Does your child have any issues with vision and/or hearing
or do you have any concerns? ______No ______ Yes
(IF YES: please check below and describe
(for example, wears glasses for reading) _________________________________________
(for example, wears hearing aid) _________________________________________
4. In the past year, has your child had any serious illness or injury?
(IF YES: What? Any special instructions or considerations for school?)
5. a. Does your child have an ongoing health condition
that may affect him or her at school?
(IF YES: What? Please circle: asthma, diabetes, serious allergy, epilepsy, CF, cancer, heart condition, or other.)
b. Does this health condition affect your child's learning or participation in activities at school? ______ No ______Yes
(for example, fatigue; ability to focus, frequent absences.
(IF YES: How?)________________________________________________________________________________
6. Does your child have health insurance? ______ No ______Yes
7. Name of Childs Physician: __________________________________________Phone:__________________________
8. Name of Child’s Dentist: ___________________________________________Phone:__________________________
Consent: I, the parent/guardian of the above named child consent to communication and exchange of health
information between the school nurse and my child’s physician and/or dentist regarding immunizations, physical
exams, medications and current health status. ______No _____Yes
Should a serious illness or accident occur and school personnel are unable to contact parent(s) or guardian(s),
permission is granted for emergency medical care to be given as necessary including transport to the nearest hospital.
Parent / Guardian Signature: _____________________________________ Date: ______________________
Parental Consent for the Administration of
Child's Name: _______________________________________ Date of Birth: ____________ Grade: ____________
Medication Allergies or Sensitivities: _________________________________________________________
I give my permission for my child to receive medication list below on this form as deemed necessary by the
School Nurse or School Staff as delegated by the Principal. I understand that the generic equivalent
medication may be used. The dose of medication will be as listed on the medication label according to age
and/or weight. If your physician has requested a dose above or below this amount, please note the dose on
this form. The school nurse does have a supply of these medications.
Please check which medications you give permission for your child to receive during the school day.
non-aspirin pain reliever/fever reducer (“Tylenol”)
pain reliever/fever reducer (“Motrin”)
for minor wounds, abrasions
_____anti-itch sprays or creams-
for rashes, bug bites, minor skin irritations
_____topical oral pain reliever-
_____Epi-Pen- used in an emergency allergic reaction only
_____I do not want my child to receive any medication while at school.
Parent / Guardian Signature: _____________________________________Date:______________________
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