In the event of an emergency, this form will be given to medical personnel.

    Does the Washington School have permission to have your child transported to a hospital? Yes _____ No _____ If no, what procedure do you wish to follow in an emergency? ______________________________________________________________________________

    Physician’s Name_____________________________________Phone _____________________

    Dentist’s Name______________________________________Phone ______________________

    Hospital/Medical Insurance Carrier and Policy#_______________________________________

    To better serve your child’s medical and physical needs, please check the following that pertain to your child:

    Heart Condition____        Autism____       Hearing Loss____            Vision Loss____

    Cerebral Palsy_____        Asthma____       Hearing Aid____ Wears Glasses____

    Diabetes____                  Migranes___       ADD/ADHD____            Spina Bifida____

    Brain Injury____ Lactose Intolerant____                              Seizure Disorder_____

    Does your child take medication?       Yes____ No____ If yes, for what condition __________

    Medication______________Dose_____________Taken daily___________As Needed_______

    Is this medication to be given at school ____at home_____or both_________

    Is your child allergic to any medicines? Yes_____ No_____ Name of medication:____________________________________________________________________

    Is your child allergic to any types of foods? Yes_____ No _____ Names of foods:


    What medicine needs to be given in case of an allergic reaction? __________________________

    Have you provided the Nurse with the medication and filled out a release form giving permission to administer the medication? Yes _____ No _____

    If the answer is no you must contact the Nurse immediately at 446-7467

    Does your child use a wheelchair?_______ A walker?_______ Other equipment _____________

    Does your child require any special nursing procedures during the school day?

    Yes_____ No___   If yes, what procedures ___________________________________________

    Please include any additonal information that you believe will assist us in keeping your child healthy________________________________________________________________________

    Parent/Guardian Signature___________________________________Date_________________