Ball-Chatham Community Unit School District No. 5

201 W. Mulberry St., Chatham, IL 62629  217/483-2416  Fax 217/483-2940  www.chathamschools.org

Health Information Form Student Name: ____________________________________________ CONDITION / ILLNESS

YES Please

NO Circle

ADD

YES

NO

Allergy to _______ (Please include any Foods)

YES

NO

Allergy to Medications

YES

NO

YES

NO

YES

NO

Glasses / Contacts

YES

NO

Hearing Loss

YES

NO

Migraines / Frequent Headaches

YES

NO

Seizures

YES

NO

Stomach Concerns

YES

NO

Other (Disabilities, Emotional Concerns etc.)

YES

NO

Circle one or both Asthma / Seasonal Allergies (circle one or both) Diabetes

Information about Condition

Grade: ___________ Medication for Condition

In the event of an emergency as a result of a serious injury or illness, permission is hereby granted to transport my son/daughter to a medical facility and to provide necessary treatment. I understand that an attempt will be made by the school administration and/or the attending physician to contact me or my spouse. If the physician is unable to communicate with me or my spouse, permission is hereby granted to the attending physician to proceed with necessary medical or surgical treatment in the best interest of my child, and if necessary to admit him/her to a medical facility.

Hospital Preference ___________________________________ Release of Information I give permission to the Ball-Chatham School Nurses and Administrators to share my child’s medical information with employees, medical personnel, and/or adults responsible with my child’s health needs. I understand that this authorization is in effect while my child is a student enrolled in Ball-Chatham Schools from the date below and I have the right to revoke permission in writing.

Parent Signature _______________________________

Date ___________________