Health Information Form 24-25 School year

Health Information Form 24-25 School year - LRSD
To better serve our families in the LRSD, it is important for our Nurses to be able to have up-to-date medical information on each of our students.
Student First Name*
Student Last Name*
Student ID Number*
Student Grade*
Student School*
Does your student have any allergies, conditions, disabilities, or illnesses?*

YesNo
If you marked Yes, please specify
Does any of the above health concerns require special attention, or medications, while at school?*

YesNoN/A
If you marked Yes, please list.
Medications: All medications should be given at home unless it's given 3 times a day, or given at a specific time, as indicated on the prescription bottle. No over-the-counter (OTC) medication will be given
Will your student need to take daily medication?*

YesNo
Medication #1 name, dosage, time given
Medication #2 name, dosage, time given
Is your child prescribed medication that could be given at school during an emergency?*

YesNo
If you marked yes, please specify

AlbuterolEpi PenGlucagonAdrenal Crisis MedicationSeizure MedicationFactorOther
If your student needs to take daily medication the parent /guardian will need to bring the medication in the original container, to the school nurse, and complete the required forms. Please initial with your mouse this understanding.

Clear
Does the student wear glasses or contacts?

YesNo
Does the student use hearing assistive device?

YesNo
The Health Services Department of the Little Rock School District provides Vision and Hearing Screenings to students in grades PK, K, 1st , 2nd , 4th , 6th, and 8th grades and any other students as requested. This services is free to families. If you sign below your Health Insurance will be billed. You will NOT get a bill. You will NOT have a copay. Please SIGN YOUR NAME BELOW to consent to release education records related to vision and hearing screenings. The agency that helps us only sees the date of the screening, not the results. In compliance with the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 123g; 34 CFR Pan 99)

Clear
Insurance / Health Care Provider Information

ArKids / MedicaidPrivate InsuranceOther
Insurance ID Number
Please SIGN BELOW - I give consent for emergency medical treatment. I understand that I will be responsible for payment of any and all medical care services, including but not limited to emergency care that is not covered by the student’s health insurance. I give consent for this information to be shared with my child’s teacher and appropriate school staff. I certify all information given is correct.*

Clear
Should be Empty:

Health Information Form 24-25 School year - LRSD