Kelton Independent School District 16703 FM 2697 Wheeler, Texas 79096 (806) 826 – 5795 (806) 826 – 3601 [fax]
STUDENT MEDICAL INFORMATION
Child’s Name Parent’s Name
Student’s Health Concerns – Disabilities, Conditions, Medical Alerts:
List ALL Drug Allergies/Sensitivies:
My Child Regularly Takes the Following Medications:
Please place a check (√) or an X in the space(s) that apply. I give consent to the school to provide my child with the following over-the-counter medicines: Chlorasceptic Lozenges, Cough Drops, First Aid Cream, Medi Quick Spray, Orajel, Sting Kill, Vaseline, Contact Solution, Contact Lubricating Eye Drops I choose to not provide any health information related to my child to the school. I realize that this could adversely affect him/her. I give consent for the exchange of my child’s immunization information between the school and all other healthcare providers, as needed.
Parent/Guardian Signature
Date
Kelton Independent School District 16703 FM 2697 Wheeler, Texas 79096 (806) 826 – 5795 (806) 826 – 3601 [fax]
INFORMACION MEDICA DEL ESTUDIANTE Nombre del Niño Nombre del Padre Problemas de la salud del estudiante - Condiciones médicas, Alarmas médicas, descapacitades
Haga una lista de TODAS las allergies/sensitividades a las drogas:
Mi niño regularmente toma las siguientes medicinas:
Favor ponga una marca (√) o una X en el espacio que aplica a su niño Yo doy permiso a la escuela Kelton para proveer a mi niño con las siguientes (over the counter) medicinas: Lozenges Chlorasceptic, First Aid Cream, Medi Quick Spray, Orajel, Sting Kill, Vaselina, Solucion para los contactos, Gotas de los ojos para lubricar a los contactos. Yo escojo no proveer a la escuela informacion de salud ninguna relacionado a mi niño. Me doy cuenta que esta decision podrá tener un efecto adverso para el/ella. Yo doy permiso para compartir la informacion de imunizaciones entre la escuela y todos otros preveedores de salud, si sea neceario.
Annual Student Medical Health Information. Dear Parent/Legal Guardian: In order to be able to assist in a MEDICAL EMERGENCY situation concerning your ...
In case of high fever or a medical emergency an attempt will first be made to contact the parent or guardian. In the event I cannot be reached, my child may be ...
Medicamentos: todos los medicamentos deben tener una fórmula médica o una nota adjunta de los padres a este formulario. Mi hijo/a toma los siguientes ...
If you desire a conference with the school nurse, please call for an appointment. ... Do we have your permission to call your child's doctor for more information ...
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14 ene. 2019 - NEW address: ... (Must provide birth certificate or court documentation.) From (name):. To (name):. From (name):. To (name):. Parent/Guardian ...
... la parte de atras). Fecha de la ultima vacuna del Tetano (TD, DTP, or Tetanus) ... (el excursionismo, el paseo en barco, la natación, subiendo etc.) Si No Si sí, ...
... facilitate the education of the child named above. Thank you for your attention. □Diagnosis □Treatment/Medications □Recommendations □Limitations (PE) ...
... or a homeless situation, please contact Cheri Jacobson, the Granite School District Homeless Liaison at 2500 South State Street, Salt Lake City, Utah 84115; telephone number (385) 646-4678; email [email protected]. RETURN THIS FORM TO
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Tiene alguna restricción en cualquiera de los programas físicos? (el excursionismo, el paseo en barco, la natación, escalando etc.) Si No Si sí, explique.
All prescription medications given at school MUST have a new HFISD Medication Permission form signed by the physician and parent/guardian each school ...
For all students: Active Duty: Army, Navy, Air Force, Marine Corps, or Coast Guard ... American Indian or Alaska Native - A person having origins in any of the original peoples of North ... the Philippine Islands, Thailand, and Vietnam. Black or ...
agrees to use these student works and information only in the manner as defined in the Student. Handbook to promote ... crabbing or fishing for commercial purposes? _______No. _______Yes. 2. .... School district staff and parents or guardians of stud
Este cuestionario de residencia (Año Escolar 2011-2012) se le entrega a TODOS los estudiantes para asegurar que nuestro distrito cumple con el Acta ...
records without your prior written consent, you must notify the district in writing within ten. (10) school days of child's first day of instruction for this school year.
Carrión may have felt the urge to achieve fame, to facilitate attaining his dream of going to Europe (3,6). At the time, it was difficult to go to the areas where the ...
Hog farms or feedlots .... Pakistán, las Islas Filipinas, Tailandia y Vietnam. Negro o ... Nativo de Hawai u otras islas del pacífico – Una persona con orígenes o de ...
Indemnización y eximición de responsabilidad. Por el presente el Participante acepta indemnizar, defender y eximir de responsabilidad a Stanford por cualquier ...
Parent: Please complete the following only if you do not want your child's information released to a military recruiter or an institution of higher education without ...
Name of Caretaker/Day Care: ... must notify the District in writing within 10 school days of student's first day of instruction of this year. ... Honey bees p. Goat farms.
