1002887231_32799 1_2

FAMILY HISTORY/MEDICAL EMERGENCY

2019/2020

Student Information:
Student Name: _______________________________________ Grade_______ Date of Birth _____/_____/_____
Street Address: _________________________________________________ Home Phone: ___________________
City: ______________________________________________ State: _______________ Zip: _________________
Mother’s Name: ________________________________ Father’s Name: ____________________________
Home Phone: __________________________________ Home Phone: _____________________________
Work Phone: __________________________________ Work Phone: ______________________________
Cell Phone: ___________________________________ Cell Phone: _______________________________
E-Mail: _______________________________________ E-Mail: __________________________________
List two local contacts if parents cannot be reached:
Name: ________________________________________ Name: ____________________________________
Home Phone: __________________________________ Home Phone: ______________________________
Work Phone: ___________________________________ Work Phone: ______________________________
Cell Phone: ____________________________________ Cell Phone: _______________________________
E-Mail: _______________________________________ E-Mail: __________________________________
Please provide the following medical information:
Allergies: ___________________________________________________ Epi Pen has been prescribed? □ Yes □ No

Does your child have Asthma? □ Yes □ No Does your child take medication for asthma? □ Yes □ No

Does your child have Diabetes? □ Yes □ No Does your child take medication for Diabetes? □ Yes □ No

Does your child have Sickle Cell Disease? □ Yes □ No Does your child take medication for Sickle Cell? □ Yes □ No

Health History: (List any pertinent medical history, injuries, physical limitation, etc.)
__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medication(s) presently taking:________________________________________________________________________

Medication(s) required at school: _______________________________________________________________________

*If your student has a chronic medical condition that might lead to a potential medical emergency, please make an
appointment with the school administrator and/or nurse prior to your student entering school.

Medical Insurance Company: ___________________________________ Policy #: _____________________________

Name of Doctor to be called: ___________________________________ Phone #: _____________________________
Name of Dentist to be called: ___________________________________ Phone #: _____________________________
Name of hospital to be taken to: ______________________________________________________________________

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FAMILY HISTORY/MEDICAL EMERGENCY

2019/2020

Medication Administration and Policy:

All medication will be administered only with the signed consent of parent/guardian and under the
assessment/discernment of the school nurse/FCA staff. Please note that all medication administered are documented. If
your child requires medication during the school day, including medication such as an inhaler and/or an EPI-PEN,
a Medication Administration Form must be on file in the clinic. The form must be signed by a parent (and by a
physician for prescription medication) annually. It is recommended that the first dose of any new medication be
administered at home.

Prescription medications must be brought to the school nurse by the parent in the current, original, properly-labeled
container, as dispensed by the pharmacist or physician. The parent must deliver ALL medication (over-the-counter and
prescription) to the school nurse for verification and inventory. NO medication of any kind may be carried on a student’s
person without permission from the school nurse, with the exception of cough drops. All medication must be picked up by
the parent at the end of the school year or upon discontinuation of use. Any medication not picked up by the end of the
school year will be discarded.
Listed below are the medications available to your student for minor medical complaints. Please INITIAL only the
medications that you give permission for FCA to administer to your student.
Acetaminophen/Tylenol____ Pepto-Bismol____ Tums____ Hydrocortisone Cream____ After-Bite_____
Ibuprofen/Motrin____ Benadryl____ Visine____ Antibiotic Ointment____ Emetrol_____
I have read and understand the medication administration policy. I give FCA staff permission to administer the initialed
medications listed above.

_________________________________________ ____________________________
Signature of parent Date

Medical Emergency

In case of emergency, I/we authorize any representative of FCA to present above stated minor to a medical treatment
center, and do consent to an x-ray, exam, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be
rendered to the minor under the general practitioner or surgeon licensed to practice in any state of the United States, and
do hereby consent to the same like treatment for dental diagnosis or treatment by a dentist licensed to practice in any state
in the United States. I/we understand that I/we shall be fully responsible for, and agree to pay for, all costs and expenses
incurred in connection with such medical services rendered to my child pursuant to this authorization.

Parent/Guardian Signature: ______________________________ Date: _________________________.