Maple Shade School District Student Medical Information Student’s Full Legal Name (please print) _____________________________________________ Gender: Male / Female Student’s Legal Home Address_________________________________________________________________________ Contact Telephone # (

) ______________________ Date of Birth _____________ Grade_____ Homeroom ______

Physician

Telephone (

)

Date of Last Medical Exam ___________________________________________________________________________ Dentist

Telephone (

Does Student Have?

Yes/No

Description

)

Does Student Have?

Yes/No

Description

Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Disorder (ADD)

Life Threatening Allergy Allergy – Food/ Drug *Please List*

Allergy – Seasonal

Convulsive Disorder

*Please List*

Food Restrictions

Headaches

Asthma

Lyme Disease

Diabetes

Hearing Problem

Neuromuscular Disease

Vision Problem

Arthritis

Psycho – Social Condition

Sickle Cell Disease

Other

Heart Condition

Other

List any medications presently being taken, dosage and duration of treatment:

List and describe any serious illness, injury, broken bones or operations during the past year:

Does child have Health Insurance? Yes

If yes, name of insurance company

No

NJ FamilyCare provides free/low cost health insurance for uninsured children and certain low income parents.

For more information, call 1800-701-0710 or visit www.njfamilycare.org to apply online. You may release my name and address to the NJ FamilyCare Program to contact me about health insurance. I understand that relevant information regarding my child’s health may be shared with appropriate school personnel and other healthcare providers as necessary. I, the undersigned parent/guardian of above named student, do hereby CONSENT, in advance to any emergency treatment and hospital care rendered to the student in the event that any situation arises during school hours or during school activities which would require emergency treatment or care. I understand that all reasonable efforts will be taken to notify me before any action is taken. Signature:

Print Name:

Date:

Written Consent required pursuant to 20 U.S.C.§ 1232g (b)(1) and 34 C.F.R. 99.30 (b).

04/2016