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RSSP Student Information & Medical/Emergency Form
Intake Meeting Date:______________________ Student’s Name_____________________________ Home School_____________________________
Address_____________________________________ City, Zip____________________ __________
Current Age_____ Birthdate___/____/______ Gender: M F Ethnic Origin_________________
Guardian______________________________ Relationship to Student__________________________
Address__________________________________________ City, Zip___________________________
Home Phone_________________ Work Phone_________________ Cell Phone___________________
Guardian______________________________ Relationship to Student__________________________
Address_________________________________________ City, Zip_____________________________
Home Phone__________________ Work Phone_________________ Cell Phone__________________
TWO ADDITIONAL EMERGENCY CONTACTS REQUIRED:
1. _____________________________________relationship_______________ Address__________________________________________________________ Home Phone__________________ Cell/Work Phone_____________________ 2. _____________________________________ relationship_______________ Home Phone___________________ Cell/Work Phone____________________ Does the parent/guardian support the student’s enrollment to the RSSP? YES NO Current Grade Placement: 6 7 8 9 10 11 12 Is student currently on probation or under court supervision? YES NO If “yes”, please indicate name of probation officer:_____________________________________ Is student currently involved with a truancy officer? YES NO If “yes”, please indicate name of officer:_____________________________________________
Is student involved with any social service agency (DCFS, DHS, YSB, etc.)? YES NO If so, please
explain.


ADDITIONAL EMERGENCY MEDICAL INFORMATION FOR ________________ This form has been
developed to be in compliance to provide medical information pursuant to HB 5939. When this form is completed it will be placed in a student
temporary file in the event of a student health emergency.
ADDITIONAL CONTACT INFORMATION
State law mandates that students not be released during emergency/disaster situations to any person not listed in writing.
Please list additional persons you would authorize to transport your child in an emergency.

Name_____________________Address____________________Phone______________
Name_____________________Address____________________Phone______________
Name_____________________Address____________________Phone______________
Name_____________________Address____________________Phone______________
Known Medical Conditions__________________________________________________
Current Medications or Chronic Illness________________________________________
_______________________________________________________________________
If medication must be administered during school day, please list the following:
Medication _______________________Dosage_________________Time____________
Medication _______________________Dosage_________________Time____________
Known Allergies__________________________________________________________
Possible Symptoms/Allergies________________________________________________
My child may________or may not________have Tylenol during the school day.
My child may________or may not________have Ibuprofen during the school day.
My child may________or may not________have cough drops during the school day.
Doctor___________________Address______________________Phone_____________
I, _______________________________________________, confirm that I am primarily responsible for
administering medication to my child. However, in the event that I am unable to do so or in the event of a medical emergency, I hereby authorize Marshall/Putnam/Woodford Regional Safe School Program and its employees and agents, in the behalf and stead, to administer or to attempt to administer to my child (or allow my child to self-administer, while under the supervision of the employees and agents of the school district), lawfully prescribed medication in the manner as listed on the medication container or so specified in writing by me. I acknowledge
that the administration of medication to my child will be performed by an individual other than a
school nurse, and I specifically consent to those practices.
I further acknowledge and agree that, when the lawfully prescribed medication is so administered or attempt to be administered, I waive any claims I might have against the Regional Safe School Program, its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless and indemnify the Regional Safe School Program, its employees and its agents, either jointly or severally, from and against all claims, damages, causes of action, or injuries incurred or resulting from the administration or attempts I authorize the RSSP to secure emergency medical care or transportation when I, or my designated medical contacts cannot be immediately reached and it’s determined that immediate action is required. If time allows for a preference, please use _________________________Hospital. _____________________________/____________________________/_____________ Parent/Guardian signature _____________________________/____________________________/_____________ Parent/Guardian signature

Source: http://www.roe43.k12.il.us/word/2008_RSSP_Student_Information_Form.pdf

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