Nashoba Regional High School Return to School Nurse School Health Services: Student Emergency and Health Record School Year 2011/2012 Sept. 2011 Grade:_______ Student Name Date of Birth Birthplace Mother/Guardian Employer Father/Guardian Employer Parent/Guardian Email SIBLINGS TELEPHONE NUMBERS: Include extensions and other prompts Work/Daytime Phone Cell Mother/Guardian 1 Father/Guardian 2 With whom does the child reside? Name & Address, if different Primary Language at Home EMERGENCY CONTACTS: LOCAL persons to be notified in case of an emergency or illness, when you are unable to be reached. Your child will only be released to the care of those listed below. Relationship Home/Daytime Phone Work, if different ** NOTIFICATION REGARDING STUDENT IDENTIFICATION: Throughout the year, faculty, staff, and the administration attempt to acknowledge and celebrate the achievements, work and contributions of students and community members. We do this through the display of work, verbal recognition, and through various printed, electronic, recorded, and photographic mediums. Also, your son's name and phone number WILL be listed in a student directory unless you circle the following: Do NOT include my child's information or photograph. **Under the No Child Left Behind Act, name, address and phone number of secondary students will be released to the U.S. Military unless you indicate that you do NOT want your child's information released. Circle DO NOT RELEASE, if applicable. HEALTH INSURANCE: Name of Company Mass Health No Insurance
If you have no health insurance, Massachusetts has health insurance plans that will provide uninsured children withaffordable health care (restrictions may apply). Please contact the school nurse for more information about these programs. All communications will be confidential. CONFIDENTIAL INFORMATION: I grant permission to the school nurse, athletic director, and/or trainer to share health information about my child, on a need to know basis, with his/her teachers, coaches, and support staff. YES NO MEDICAL RELEASE: I grant to the Nashoba Regional School District personnel, the right to obtain emergency medical treatment for my child during the period of the school year. I give permission for ambulance transport to the nearest hospital. Payment for any and all medical treatment is the financial responsibility of the parent/guardian. Parent/Guardian Signature Please turn page over to complete side 2 of this form. HEALTH HISTORY: LIFE THREATENING ALLERGIES Please indicate if your child has a physician verified allergy to any of the following. *If yes, please provide official
documentation by your child's physician and an Emergency Care Plan to the school nurse at the beginning of the school year. Written prescriptions are required for all Epi Pens, Benadryl and inhalers. Bee Stings Medication Describe your child's reaction. Emergency Care Plan
Does ___________ carry his/her own Epi Pen?
Indicate treatment for allergic reaction at school.
Illness/Chronic Conditions: Indicate if your child has experienced any of the following. If yes, please explain condition below. HEALTH CARE PROVIDERS: DENTAL: Dental Insurance
Does your child visit the dentist every six months? Yes No Date of last exam. SPORTS: Do you know of any reason your child should not participate in sports? Please indicate.
***A physical exam is required annually for school sports at the middle and high school level. MEDICATIONS: Please list prescribed and over the counter medications your child takes. Include herbal treatments. MEDICATION ADMINISTRATION: Per NRSD protocol, and with your signature below, our school nurses may dispense the following over-the-counter medications after assessment of your child: Ibuprofen (Advil, Motrin)____ Acetaminophen (Tylenol) ____ Antacid (Tums)____ Benadryl ____ **To DENY permission for the medications listed above, please check here. _____ All other medications require a written prescription from your physician and your signed permission. Please note: The above OTC medications may be given only once during the school day. Also, the school nurse may use first aid treatments, including topical ones, to treat allergic rashes, insect bites, toothaches, minor wound infections and minor burns unless otherwise indicated by parent/guardian. Parent/Guardian Signature
ESCOLES OFICIALS D’IDIOMES FRANCÉS NIVEL: “BÀSIC” CURSO 2009-10 CONTENIDOS Contenidos morfo sintácticos: Oración simple (declarativa con verbo en forma afirmativa o negativa, pasiva, interrogativa, exclamativa e imperativa afirmativa i negativa). Oración compuesta, expresión de relaciones lógicas (disyunción, oposición, causa, relaciones temporales, consecuenc
LEY N° 5326 CÓRDOBA, 17 DE ENERO DE 1972 VISTO: LA AUTORIZACIÓN CONCEDIDA POR EL COMISARIO NACIONAL POR DECRETO Nº 717-71, ARTICULO 1º, PUNTO 1.1.1. Y LAS POLÍTICAS NACIONALES NROS. 3, 21,25,28 EN EL EJERCICIO DE LAS FACULTADES LEGISLATIVAS QUE LE CONFIERE EL ARTICULO NOVENO DEL ESTATUTO DE LA REVOLUCION ARGENTINA, EL GOBERNADOR DE LA PROVINCIA DE CÓRDOBA, SANCIONA