Medical Information for Students
- This form is only to be completed by parents of currently enrolled students when there is a change in medical information, or for new students with medical issues. If there no changes from the previous school year, you do not need to complete this form.
- Parents may also complete this form at any time during the year when there are medical information changes.
- Responding "yes" to any of the questions below will open up new questions.
- if you have difficulty with this form, send a note to our webmaster. If you have a medical question, please contact district nurse Julie Liskiewicz via email or phone: 734-424-4100 ext. 1051.
Please list any food allergies.
Please list any daily medications needed (write n/a if none).
Please list any rescue medications needed (write n/a if none).
Please list any medication allergies.
Please list any bee or insect allergies.
Please list any medications needed/used in the event of an insect sting or bite.
Please list any other serious allergies.
Please list any daily medications (write n/a if none).
Please list any rescue medications used/needed (write n/a if none).
Please list this student's asthma triggers.
Please list any physical education restrictions due to asthma (write n/a if none.)
Please list any daily prescribed treatments to be used in school (write n/a if none).
Please list any rescue treatments or medications (write n/a if none).
Please list any currently prescribed treatments to be used in school.
Please list all oral medications (for any condition) that this student is taking.
Please list any special scheduling of lunch and/or physical activities (write n/a if none).
Type of seizure disorder.
List any physical education restrictions due to this condition (write n/a if none).
Please list any daily medications needed in school (write n/a if none).
Please list any rescue medications (write n/a if none).
Please describe any heart conditions.
Please describe any other life-threatening medical conditions not noted above.
For each prescription medication your child currently takes, please list the medication name, when taken, and what it is taken for.
Please list any dietary restrictions.
Permission to Share Medical Information:
I agree that the school nurse may share health information with appropriate school personnel to aid present and future educational decisions, and, if needed, make and distribute an emergency plan based on this information.
(For example: classroom teacher, para educator, lunchroom personnel, bus driver, or other staff as appropriate.)
Permission for Emergency Treatment
I give permission for release of information on this form for confidential use in meeting this student's health and educational needs in school. I understand that any changes regarding this student's health history need to be communicated to the school nurse/principal. I hereby authorize officials of the district to contact directly the person(s) named within this registration information and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency for the health of the student. In the event that the parents/guardians or contact persons named in this registration cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for the health of the student. I will not hold the school district financially responsible for the emergency care and/or transportation of said student.
(This applies only to medically necessary treatment in the absence of a parent or guardian decision.)