Changes in Medical Information for Existing Students

Instructions

  • This form is only to be completed by parents of currently enrolled students when there is a change in medical information. 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.
  • Parents who are enrolling new students will relay this information during the online registration process.
  • 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.

Parent's Full Name​​
Student's Full Name​​
Parent's Email​​​
Best Daytime Phone​​

Food Allergies

Does this student have any food allergies? ​​
Please list any food allergies. ​​​
Are any of these food allergies life-threatening? ​​​​​
Please check all that apply. ​​​​
Please list any daily medications needed (write n/a if none).​​
Please list any rescue medications needed (write n/a if none). ​​

Medication Allergies

Does this student have any medication allergies?​​​
Please list any medication allergies.​​​​
Are any of these medication allergies life-threatening?​​
Please check all that apply.​​​​​​​

Bee/Insect Allergies

Is this student allergic to bee or insect stings and bites?​​
Please list any bee or insect allergies. ​​​
Are any of these allergies life-threatening? ​​​
Please check all that apply. ​​​
Please list any medications needed/used in the event of an insect sting or bite. ​​​

Other Allergies

Does this student have any other serious allergies not noted above?​​
Please list any other serious allergies.​​​​​
Please check all that apply.​​​​
Please list any daily medications (write n/a if none).​​​
Please list any rescue medications used/needed (write n/a if none).​​

Asthma

Does this student have asthma? ​​
Please list this student's asthma triggers. ​​​
Please check all that apply. ​​​
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). ​​
Date of last hospitalization related to asthma (write n/a if none). ​​​
Name and phone number of treating physician. ​​

Diabetes

Does this student have diabetes?​​
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).​​​
Name and phone number of treating physician. ​​

Seizure Disorder

Does this student have a seizure disorder?​​​​
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).​​​​
Name and phone number of treating physician. ​​​

Other Health Conditions

Has this student had the chicken pox? ​​​
Please list the approximate date the student had chicken pox. ​​​

Does this student have a heart condition? ​​
Please describe any heart conditions​​​​. ​

Does this student have any other life-threatening conditions not noted above? ​
Please describe any other life-threatening medical conditions not noted above. ​​

Is this student currently taking any prescription medications? ​​
For each prescription medication your child currently takes, please list the medication name, when taken, and what it is taken for. ​​​​

Does this student have any dietary restrictions? ​
Please list any dietary restrictions.​​​

Acknowledgements

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.)


Please provide an email address where we can send a link to your current form.

Email Address :