Portal

(To be completed by the student’s parent/guardian)

Yes Declined

Attending:*

Male Female

Yes No

Student ID:

Student Name - First*

Last*

Date of Birth*

Name:

Relationship:

Phone:

Home:

Cell:

Work:

City:

State:

Zip:

Name:

Relationship:

Phone:

Home:

Cell:

Work:

Street Address:

City:

State:

Zip:

EMERGENCY CONTACT:

Name:

Relationship:

Emer.Home Phone:

Emer.Cell:

Emer.Work:

Physician 1:

Physician 1 Phone:

Physician 2:

Physician 2 Phone:

Hospital of Choice:

Drug Allergies:

Medical Information:

1. Diagnosis & special conditions:

a. At what age was diagnosis made?

Yes No

2. Does your child have seizures?

a. If yes, the date of the last seizure?

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3. Does your child require help in feeding?

Yes No

4. Does your child require a special diet?

a. Please list food allergies (if any):

Yes No

5. Does your child take medication at home ?

Yes No

6. Is your child required to receive medication while in school?

Walks Wheelchair Braces Crutches

7. What is your child’s ambulatory status?

Yes No

8. Is your child toilet trained?

Comments:

9. List physical disabilities you feel are important for your child’s teacher to know about.

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Email*

Signature - use mouse

Date:

Required fields

Comment

ESY STUDENT INFORMATION

Current School: *

Parent/Guardian 1:

Street Address:

Parent/Guardian 2:

Do you give the ESY permission staff to photograph (photos/videos) your student? (It may be used for publicity and/or classroom project purposes.)

Please answer each of the following questions about your child by checking the ‘yes’ or ‘no’ blanks to the right of each question. If you chose, you may add a comment to finish answering the question.

a. If yes, please list medication(s), purpose of medication, dosage & time it is to be given. You must provide a physician’s script to have your child’s medication administered by the school nurse during the ESY program. Medication must be in the original and labeled container(s). Parent/Guardian must also provide written permission allowing the school nurse to administer medication(s).

10. Please comment on any other information you would like our staff to know about your child (fears, dislikes, etc.) Please include specific daily routines.

a. If yes, please list the name of the medication, dosage and time administered. Please indicate how your child takes his/her medication.