STUDENT HEALTH AND EMERGENCY UPDATE
Student Name:______________________________________________________							Grade:___________
Parent/Guardian:______________________________________________							Home phone:________________________
911 Address:_________________________________________________							Cell number:________________________
We STRESS the IMPORTANCE of giving the school several routes to reach you in case of an emergency.
If the phone is disconnected, phone number changed, or job changes PLEASE NOTIFY THE SCHOOL
IMMEDIATELY!
	Name			Place of Work				Work Number
Father_________________________________________________________________________________________
Mother________________________________________________________________________________________
List 2 nearby relatives or neighbors who will assume temporary care of your child if you can not be reached
	Name			Home phone				Work/Cell phone
1._______________________________________________________________________________________________
2.________________________________________________________________________________________________
CURRENT HEALTH CONCERNS AND/OR LIMITATIONS:_________________________________________________
_________________________________________________________________________________________________
SIGNIFICANT ILLNESSES:			(circle any condition your child may have)
Heart Disease/Diagnosis_______________________________________						Diabetes/Diagnosis Date_____________________
Kidney Disease/Diagnosis______________________________________						Significant Allergies_________________________
Seizures____________________________________________________						Date of last seizure__________________________
Hypoglycemia/Treatment_________________________________						Bowel/Bladder Control_______________________
Asthma medication_________________________________________________________________________________
Asthma Triggers____________________________________________________________________________________
Chicken Pox________________			Approximate date_______________________
Major Illness (specify) ______________________________________________________________________________
Other Health related information: Physical and/or emotional__________________________________________
________________________________________________________________________________________________
Glasses_____________________			Contact lenses_________________________
Current Physician:______________________________					Phone number:________________________
LIST ANY MEDICATION THAT YOUR CHILD TAKES ON A ROUTINE DAILY BASIS:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
RELEASE FOR EMERGENCY TREATMENT
The Ashdown School District does not assume any financial responsibility, but does wish to provide the best
service possible in an emergency.  By signing this release, you are giving us, Ashdown School District,
authority to call a physician or to transport your child to the hospital if you or the alternate adult
cannot be reached immediately.  By signing this release, I give my permission to the school nurse to
release all health information to the other professionals involved with my child.
					_____________________________________________________
					Signature of parent or guardian
My child is covered by:
(     ) Medicaid		(     ) Other insurance
(     ) ArKids		(     ) No insurance