THIS FORM MUST BE COMPLETED AND BROUGHT TO SCHEDULE PICK-UP

PLYMOUTH-CANTON COMMUNITY SCHOOLS P-CEP STUDENT MEDICAL INFORMATION & STUDENT HANDBOOK AWARENESS FORM 2017-18 PLEASE NOTE, IF THIS FORM IS NOT FILLED OUT AND RETURNED AT SCHEDULE PICK-UP, YOUR STUDENT WILL NOT RECEIVE THEIR SCHEDULE.

LEGAL LAST NAME

COMTACT PHONE

FIRST NAME Y /N UNLISTED?

STUDENT ID#

STUDENT RESIDES WITH: (PLEASE CIRCLE)

/ / BIRTH DATE

MIDDLE INITIAL

HOME SCHOOL Canton, Plymouth, Salem

MOTHER

MY STUDENT HAS HEALTH CONCERNS: (PLEASE CIRCLE)

FATHER YES

YEAR OF GRAD

MALE / FEMALE GENDER (CIRCLE ONE)

COUNSELOR

BOTH PARENTS

LEGAL GUARDIAN

NO

PLEASE FILL OUT THE BOXED SECTION BELOW, ONLY IF YOU ANSWERED YES TO THE ABOVE QUESTION STUDENT HEALTH INFORMATION HEALTH CONCERNS ALLERGIES ARTHRITIS ASTHMA DIABETES EMOTIONAL HEARING

HEART CONDITION KIDNEY DISEASE SEIZURES VISION WALKING / MOBILTIY OTHER

EXPLAIN:

DOES THIS STUDENT HAVE ANY PHYSICAL RESTRICTION(S)?: (PLEASE CIRCLE)

YES

NO

EXPLAIN:

PLEASE KNOW, A DOCTOR'S NOTE IS REQUIRED IF RESTRICTION INCLUDES PHYSICAL EDUCATION MEDICATION - PLEASE LIST ALL MEDICATIONS AND DOSES THIS STUDENT USES REGULARLY: MEDICATION

DOSE

MEDICATION

DOSE

MEDICATION

DOSE

MEDICATION

DOSE

PHYSICIAN AUTHORIZATION REQUIRED IF MEDICATION IS TO BE ADMINISTERED AT SCHOOL

SIGNATURES ARE REQUIRED BELOW MEDICAL EMERGENCY AUTHORIZATION STATEMENT: (PARENT SIGNATURE REQUIRED) INFORMATION PROVIDED ON THS FORM AND INFORMATION SUBMITTED ON PHYSICAL HEALTH APPRAISALS MAY BE SHARED WITH SCHOOL PERSONNEL, WHO ARE INVOLVED WITH THE HEALTH AND SAFETY OF MY CHILD. IF SCHOOL PERSONNEL ARE UNABLE TO REACH ME OR A PERSON WHOM I HAVE DESIGNATED, I HEREBY AUTHORIZED THEM TO SECURE EMERGENCY MEDICAL TREATMENT AS NECESSARY. I AGREE TO PAY ALL EXPENSES INCURRED BY THE EMERGENCY CARE.

PARENT OR GUARDIAN SIGNATURE:

DATE:

STUDENT HANDBOOK AWARENESS STATEMENT: (PARENT INTIAL / STUDENT SIGNATURE REQUIRED) I AGREE TO REVIEW THE STUDENT HANDBOOK (pcep.pccs.k12.mi.us/codeofconduct) TO UNDERSTAND THE RIGHTS AND RESPONSIBILITIES PERTAINING TO STUDENTS. I AGREE TO ABIDE BY THE RULES, PROCEDURES AND POLICIES OF THE SCHOOL DISTRICT. IF I HAVE QUESTIONS, I WILL CONTACT AN ADMINISTRATOR FOR MORE INFORMATION.

PARENT INITIALS:

STUDENT SIGNATURE:

DATE: