Dear MCHS Parent/Guardian: May, 2016 The health forms required for entrance into Morris Catholic High School can be downloaded from our school website. A letter was sent home with directions to complete this. The state of New Jersey has issued new forms. Please read carefully. Two pages are for parent/guardian to complete; two pages are for physician to complete. In addition there is an immunization form, student accident insurance information and emergency permission form, and permission to share information form all to be completed by parent /guardian. Only physicals done on these New Jersey Department of Education Athletic Preparticipation Forms will be accepted. All students participate in some form of athletics during their years at Morris Catholic, whether interscholastic, intramural or physical education classes, therefore it is a requirement that all students must have a physical EVERY school year. Please do not separate pages after completion.
Immunizations must be complete, up to date, and each one recorded with the month, day and year. New Jersey School Requirements: a) Four doses of DPT. b) One dose Tdap required for students born on or after 1/1/1997 c) Three doses of oral polio vaccine ( OPV) or inactivated polio vaccine ( IPV). d) One MMR or individual vaccinations for measles, mumps , and rubella administered on or after the first birthday. All students born on or after January 1, 1990 are required to have two doses of a measlescontaining vaccine. If the student has had the disease of measles, mumps or rubella, a serum antibody level drawn in a medical laboratory showing sufficient immunity must be submitted. e) Hepatits B: Pediatric/Adolescent Vaccine. Three dose series. OR Recombivax HB Adult Dose by Merck. Two dose series given between age 1115 yrs. f) One dose Meningococcal for students born on or after 1/1/1997 g) TB/ PPD test for students transferring to a New Jersey school from another state or country.
The emergency permission information will be used only in the event we absolutely cannot contact a parent or guardian.
These forms are to be returned to the Health Office by July 25, 2016 for fall athletes and August 15, 2016 for all other students and athletes. No student will be allowed to attend classes or participate in sports without these forms on file.
Thank you for your close attention to these necessary requirements. Please call our health office at 9736276674 ext. 126, with any questions. Have a happy and healthy summer.
Sincerely, Mr. Robert Loia Principal
Memo From the Morris Catholic Health Office May 2016
Please Note the Annual Physical Policy COMPLETE ANNUAL PHYSICALS ARE REQUIRED FOR ALL STUDENTS (NEW AND RETURNING ) ENROLLED AT MORRIS CATHOLIC HIGH SCHOOL. This policy at MC has been instituted to allow our health office to better care for both individual students and the student community as a whole. Your complete annual school physical must be current and must include a dated summary of all immunizations received to the present. ________________________________________________________________________ 1. History From 2. The Athlete / Student With Special Needs: Supplemental History Form 3. Physical Examination Form 4. Clearance Form 5. Immunizations 6. *Permission for OvertheCounter or Prescription Medications Note: * This form must be completed each school year . Please be aware – the nurse cannot give your student Tylenol, Advil or cough drops at anytime if this form is not completed by the parents and physician. It is recommended that you have this form completed with the above forms during your son/daughter’s physical examination. * If you son/daughter takes a prescription medication, uses an inhaler, or EpiPen, separate forms can be found on the health office page of our web site. These forms MUST be completed every school year. 7. Interscholastic Athletic Permission Form – page 7 Student Accident Insurance Policy – page 7 Emergency Permission – page 7 8. Emergency Contact Information page 8 Permission to share information page 8 Please make sure all forms are returned completed, dated and signed. All forms must be in the health office no later than July 25, 2016 for all fall athletes and August 15, 2016 for all other students. Note: If the student participates in a fall sport, please note that practices start August 15, 2016 Students cannot attend practice until all forms are returned to the Health Office & Athletic Forms to our Athletic Trainer. No form will be accepted if not completed in its entirety
■ Preparticipation Physical Evaluation
HISTORY FORM (Note: This form is to be filled out by the patient and parent prior to seeing the physician. The physician should keepa copy of this form in the chart.) Date of Exam ___________________________________________________________________________________________________________________ Name __________________________________________________________________________________ Date of birth __________________________ Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________ Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking
Do you have any allergies?
Medicines
Yes
No If yes, please identify specific allergy below.
Pollens
Food
Stinging Insects
Explain “Yes” answers below. Circle questions you don’t know the answers to. GENERAL QUESTIONS
Yes
No
MEDICAL QUESTIONS
1. Has a doctor ever denied or restricted your participation in sports for any reason?
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
2. Do you have any ongoing medical conditions? If so, please identify below:
Asthma
Anemia
Diabetes
Infections Other: _______________________________________________
27. Have you ever used an inhaler or taken asthma medicine?
Yes
No
28. Is there anyone in your family who has asthma? 29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
3. Have you ever spent the night in the hospital? 4. Have you ever had surgery?
30. Do you have groin pain or a painful bulge or hernia in the groin area?
HEART HEALTH QUESTIONS ABOUT YOU
Yes
No
31. Have you had infectious mononucleosis (mono) within the last month?
5. Have you ever passed out or nearly passed out DURING or AFTER exercise?
32. Do you have any rashes, pressure sores, or other skin problems?
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
34. Have you ever had a head injury or concussion?
33. Have you had a herpes or MRSA skin infection? 35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?
7. Does your heart ever race or skip beats (irregular beats) during exercise? 8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure
A heart murmur
High cholesterol
A heart infection
Kawasaki disease Other: _____________________
36. Do you have a history of seizure disorder?
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
39. Have you ever been unable to move your arms or legs after being hit or falling?
37. Do you have headaches with exercise? 38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?
10. Do you get lightheaded or feel more short of breath than expected during exercise?
40. Have you ever become ill while exercising in the heat?
11. Have you ever had an unexplained seizure?
42. Do you or someone in your family have sickle cell trait or disease?
12. Do you get more tired or short of breath more quickly than your friends during exercise?
43. Have you had any problems with your eyes or vision?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
41. Do you get frequent muscle cramps when exercising?
44. Have you had any eye injuries? Yes
No
13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?
45. Do you wear glasses or contact lenses? 46. Do you wear protective eyewear, such as goggles or a face shield? 47. Do you worry about your weight? 48. Are you trying to or has anyone recommended that you gain or lose weight?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
49. Are you on a special diet or do you avoid certain types of foods? 50. Have you ever had an eating disorder?
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
51. Do you have any concerns that you would like to discuss with a doctor? FEMALES ONLY
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
52. Have you ever had a menstrual period?
BONE AND JOINT QUESTIONS
Yes
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to miss a practice or a game?
No
53. How old were you when you had your first menstrual period? 54. How many periods have you had in the last 12 months? Explain “yes” answers here
18. Have you ever had any broken or fractured bones or dislocated joints? 19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches? 20. Have you ever had a stress fracture? 21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism) 22. Do you regularly use a brace, orthotics, or other assistive device? 23. Do you have a bone, muscle, or joint injury that bothers you? 24. Do any of your joints become painful, swollen, feel warm, or look red? 25. Do you have any history of juvenile arthritis or connective tissue disease?
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete __________________________________________
Signature of parent/guardian ____________________________________________________________
Date _____________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
9-2681/0410
■ Preparticipation Physical Evaluation
THE ATHLETE WITH SPECIAL NEEDS: SUPPLEMENTAL HISTORY FORM Date of Exam ___________________________________________________________________________________________________________________ Name __________________________________________________________________________________ Date of birth __________________________ Sex _______ Age __________ Grade _____________ School _____________________________ Sport(s) __________________________________ 1. Type of disability 2. Date of disability 3. Classification (if available) 4. Cause of disability (birth, disease, accident/trauma, other) 5. List the sports you are interested in playing Yes
No
Yes
No
6. Do you regularly use a brace, assistive device, or prosthetic? 7. Do you use any special brace or assistive device for sports? 8. Do you have any rashes, pressure sores, or any other skin problems? 9. Do you have a hearing loss? Do you use a hearing aid? 10. Do you have a visual impairment? 11. Do you use any special devices for bowel or bladder function? 12. Do you have burning or discomfort when urinating? 13. Have you had autonomic dysreflexia? 14. Have you ever been diagnosed with a heat-related (hyperthermia) or cold-related (hypothermia) illness? 15. Do you have muscle spasticity? 16. Do you have frequent seizures that cannot be controlled by medication? Explain “yes” answers here
Please indicate if you have ever had any of the following. Atlantoaxial instability X-ray evaluation for atlantoaxial instability Dislocated joints (more than one) Easy bleeding Enlarged spleen Hepatitis Osteopenia or osteoporosis Difficulty controlling bowel Difficulty controlling bladder Numbness or tingling in arms or hands Numbness or tingling in legs or feet Weakness in arms or hands Weakness in legs or feet Recent change in coordination Recent change in ability to walk Spina bifida Latex allergy Explain “yes” answers here
I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct. Signature of athlete __________________________________________
Signature of parent/guardian __________________________________________________________
Date _____________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
■ Preparticipation Physical Evaluation
PHYSICAL EXAMINATION FORM Name __________________________________________________________________________________ Date of birth __________________________
PHYSICIAN REMINDERS 1. Consider additional questions on more sensitive issues • Do you feel stressed out or under a lot of pressure? • Do you ever feel sad, hopeless, depressed, or anxious? • Do you feel safe at your home or residence? • Have you ever tried cigarettes, chewing tobacco, snuff, or dip? • During the past 30 days, did you use chewing tobacco, snuff, or dip? • Do you drink alcohol or use any other drugs? • Have you ever taken anabolic steroids or used any other performance supplement? • Have you ever taken any supplements to help you gain or lose weight or improve your performance? • Do you wear a seat belt, use a helmet, and use condoms? 2. Consider reviewing questions on cardiovascular symptoms (questions 5–14). EXAMINATION Height
Weight
Male
Female
BP / ( / ) Pulse Vision R 20/ MEDICAL Appearance • Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency) Eyes/ears/nose/throat • Pupils equal • Hearing Lymph nodes Heart a • Murmurs (auscultation standing, supine, +/- Valsalva) • Location of point of maximal impulse (PMI) Pulses • Simultaneous femoral and radial pulses Lungs Abdomen Genitourinary (males only)b Skin • HSV, lesions suggestive of MRSA, tinea corporis Neurologic c MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes Functional • Duck-walk, single leg hop
L 20/ NORMAL
Corrected
Y
N ABNORMAL FINDINGS
a
Consider ECG, echocardiogram, and referral to cardiology for abnormal cardiac history or exam. Consider GU exam if in private setting. Having third party present is recommended. Consider cognitive evaluation or baseline neuropsychiatric testing if a history of significant concussion.
b c
Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for _________________________________________________________________ ____________________________________________________________________________________________________________________________________________ Not cleared Pending further evaluation For any sports For certain sports _____________________________________________________________________________________________________________________ Reason
___________________________________________________________________________________________________________________________
Recommendations _________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ II have the above-named above-named student student and and completed completed the thepreparticipation preparticipationphysical physicalevaluation. evaluation.The Theathlete athlete does present apparent clinical contraindications to practice have examined examined the does notnot present apparent clinical contraindications to practice andand participate in in the the sport(s) sport(s) as as outlined outlined above. A copy of the physical exam is on record in participate in my my office office and can be made made available availabletotothe theschool schoolatatthe therequest requestof ofthe theparents. parents.IfIfcondiconditions tions after arisethe after the athlete hascleared been cleared for participation, the physician may the rescind the clearance the problem is resolved and the potential consequences are completely arise athlete has been for participation, a physician may rescind clearance until theuntil problem is resolved and the potential consequences are completely explained explained to the athlete (and parents/guardians). to the athlete (and parents/guardians). Name of physician, advanced practice nurse (APN), physician assistant (PA) (print/type)____________________________________________ Date of exam ________________
Address ________________________________________________________________________________________________________ Phone _________________________ Signature of physician, APN, PA _____________________________________________________________________________________________________________________
©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. HE0503
New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
9-2681/0410
■■ Preparticipation Physical Evaluation
CLEARANCE FORM
Name _______________________________________________________ Sex M F
Age _________________ Date of birth _________________
Cleared for all sports without restriction Cleared for all sports without restriction with recommendations for further evaluation or treatment for ________________________________________________
___________________________________________________________________________________________________________________________
Not cleared Pending further evaluation For any sports For certain sports______________________________________________________________________________________________________ Reason _ ___________________________________________________________________________________________________________ Recommendations _______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ EMERGENCY INFORMATION Allergies ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Other information
_______________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________
I have examined the above-named student and completed the preparticipation physical evaluation. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above. A copy of the physical exam is on record in my office and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). Name of physician, advanced practice nurse (APN), physician assistant (PA) ____________________________________________________ Date _______________ Address _________________________________________________________________________________________ Phone _________________________ Signature of physician, APN, PA _____________________________________________________________________________________________________ Completed Cardiac Assessment Professional Development Module Date___________________________ Signature_______________________________________________________________________________________ ©2010 American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine. Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. New Jersey Department of Education 2014; Pursuant to P.L.2013, c.71
Immunizations DPT Series: ( Month, Day, year ) 1. _______2. ______ 3. ________ Booster______
( 4 doses of Td or a combination of DPT, DTaP and Td to equal 4 doses ) Tdap 1. ______ ( if born on or after 11 1997 ) Polio: 1.
______2. ______ 3. _____ Booster _____
(3 doses either inactivated Polio vaccine ( IPV ) or oral Polio vaccine ( OPV ) MMR ( on or after first birthday ) 1._________ 2. ________ st nd ( Interval between 1 and 2 vaccinations must be at least 1 month )
Measles:___________ Disease* _______ Rubella: __________ Disease* _______ Mumps: __________ Disease* _______ Hepatitis B: Pediatric / Adolescent Hepatitis B Vaccine: 1. ________ 2. _________ 3. _________ OR: Recombivax HB Adult Dose by Merck
( Must be given between ages 11 – 15 years ) 1.__________ 2. ____________ Meningococcal : 1. __________ ( if born on or after 1/1/1997) Any student entering NJ schools from out of state or another country must have : TB test / PPD Date given _______ Date read _______ Result ___________ mm positive ______ negative _____ If Positive Chest XRAY Date ____________ Results _________ * If the student has had the disease of Measles, German Measles, or Mumps, a serum antibody level drawn in a medical laboratory showing sufficient immunity MUST be submitted.
2016-2017 MEDICATION REQUEST FORM The NJ Department of Education; Office of Educational Support Services, recommends that ALL MEDICATION (prescription and over the counter OTC) must be accompanied by written permission from BOTH the PARENT and PHYSICIAN. The ESC follows the recommendation that permission is required from BOTH PARENT AND PHYSICIAN for administration of any medication. In order for a student to receive any medicine, including Tylenol or Advil, the nurse needs written permission from both the parent and the physician. Prescription medication must be brought to school by the parent, unless other arrangements have been made with the nurse. It must be in the original prescription container, labeled with the name of the student, medication, dosage and name of the physician. Any OTC medication must be brought to school by the parent in the original sealed container and labeled with the student’s name. All medication is to be taken home by the parent when it is no longer needed or at the end of the school year. Unclaimed OTC medication shall be disposed of at the end of each school year. All prescription and non-prescription medications should be provided by the parent/guardian along with: written permission of the child’s physician and parent/guardian including the child’s name, purpose of the medication, the time at which (or the circumstances under which) the medication shall be administered, and the length of time for which the medication is prescribed. Only those medications which are medically necessary during school hours for a student’s well being should be sent to school. NOTE: THE VERY FIRST DOSE OF THIS MEDICATION MAY NOT BE GIVEN AT SCHOOL.
NAME OF STUDENT_________________________________DOB________________ NAME OF MEDICATION_________________________________________________ DOSAGE_______________________________________________________________ TIME TO BE GIVEN______________________________________________________ REASON FOR MEDICATION______________________________________________ MEDICATION TO BE GIVEN FROM____________________TO_________________ DATE
DATE
HOW IT IS TAKEN_______________________________________________________ EXAMPLE: BY MOUTH, INHALER, WITH FOOD, CRUSHED, ETC.
ADDITIONAL COMMENTS_______________________________________________
_______________________________ PARENT SIGNATURE/DATE _______________________________________________ TELEPHONE NUMBER
_____________________________ PHYSICIAN SIGNATURE/DATE ___________________________________________ TELEPHONE NUMBER
ADDITIONAL MEDICATIONS
NAME OF STUDENT___________________________________________
DOB________________
NAME OF MEDICATION_______________________________________________________________ DOSAGE_____________________________________________________________________________ TIME TO BE GIVEN____________________________________________________________________ REASON FOR MEDICATION____________________________________________________________ MEDICATION TO BE GIVEN FROM_________________________ TO_________________________ DATE DATE HOW IT IS TAKEN_____________________________________________________________________ EXAMPLE: BY MOUTH, INHALER, WITH FOOD, CRUSHED, ETC. ADDITIONAL COMMENTS______________________________________________________________
NAME OF STUDENT___________________________________________
DOB________________
NAME OF MEDICATION_______________________________________________________________ DOSAGE_____________________________________________________________________________ TIME TO BE GIVEN____________________________________________________________________ REASON FOR MEDICATION____________________________________________________________ MEDICATION TO BE GIVEN FROM_________________________ TO_________________________ DATE DATE HOW IT IS TAKEN_____________________________________________________________________ EXAMPLE: BY MOUTH, INHALER, WITH FOOD, CRUSHED, ETC. ADDITIONAL COMMENTS______________________________________________________________
************************************************************************************** ________________________________________
__________________________________
PARENT SIGNATURE/DATE
PHYSICIAN SIGNATURE/DATE
__________________________________ TELEPHONE NUMBER
____________________________ TELEPHONE NUMBER
4/1/10 ESC of Morris County
Morris Catholic High School Interscholastic Athletic Permission Form Student’s Name: ______________________________________________________ I, the undersigned parent or guardian hereby give to above named student permission to try-out, practice and compete in the interscholastic athletic program at Morris Catholic High School. Realizing that such activity involves the potential for injury which is inherent in all sports, I acknowledge that even with the best coaching, use of the most advanced protective equipment and strict observance of rules, injuries are still a possibility. On rare occasions, these injuries can be so severe as to result in total disability, paralysis or even death. I acknowledge that I have read and understand this warning. I agree that MCHS shall not be liable, financially or otherwise, for any physical injury of any sort sustained by above named student while traveling to or from practice or competition, or while participating in any off-season/in-season conditioning and/or weight training programs, or while practicing for or competing in the interscholastic program. I agree to guarantee the return of any and all school property and equipment issued to the student, or to compensate MCHS for such property or equipment that is not returned except where such material has been damaged or destroyed by actual use in practice or competition. Parent or Guardian Signature: _______________________________________ Date: _________________
Student Accident Insurance Policy Effective July 1, 2016 and continuing through June 30, 2017, all MCHS students are covered for medical expense incurred for treatment of accidental injuries which occur while participating in school-sponsored and school-supervised activities. This insurance is provided through the Diocese of Paterson Student and Sports Accident Insurance Policy. The student is covered while: attending school during school hours, attending school sponsored and supervised activities and traveling directly to and from school and home from either of the above. § § §
This coverage is in excess of any other insurance coverage you have your child. Your family Medical/Health Insurance Policy must be used before benefits under this plan will be available. If you go out of network of your primary insurance, out of network expenses may not be covered by BMI Benefits LLC. It is most important for you to realize this policy does not cover non-school related activities.
All claims come from the nurse’s office. An insurance form will be issued which must be completed by the trainer/nurse, the parent/guardian and the attending physician, then mailed to the insurance company within 90 days of the date of the accident. It is the family’s responsibility to report all injuries requiring medical attention immediately and obtain this form within the required time limitations. Parents should realize that any medical expenses involving their son/daughter are their responsibility and not the school’s. Parent or Guardian Signature: _______________________________________ Date: _________________
Emergency Permission As parent or guardian of the above named student, I give my permission to the authorities of MCHS to initiate or seek emergency care should he/she become sick or injured. To the hospital I grant permission for the performance of such operation and/or procedure, and/or anesthesia, as are deemed necessary. Also, to release this record requested by professional individuals and agencies. Parent or Guardian Signature: _______________________________________ Date: _________________ Page 7
Class of ______
SCHOOL EMERGENCY CARD Student Name:______________________________________________
Birth Date: ________________
Mailing Address: ____________________________________________
Home Telephone: ___________
Town: _____________________________________________________ Zip Code: __________________ Father’s Name: ______________________________ Mother’s Name: ___________________________ Father’s Cell Phone #: _________________________ Mother’s Cell Phone #: ______________________ Father’s Work Phone #: _______________________
Mother’s Work Phone #: ____________________
In case of illness, etc. list alternates in the area other than parent or guardian to be contacted: Name: _____________________________________ Telephone #: _______________________________ Name: _____________________________________ Telephone #: _______________________________ Current Health Information Please list any medical conditions of the student/minor (asthma, diabetes, epilepsy, etc.): ______________________________________________________________________________________ List any allergies or allergic reactions to medications of the student/minor: ______________________________________________________________________________________ List any medications the student/minor is presently taking: ______________________________________________________________________________________ Does student use/carry: Inhaler: ______ Yes _____ No
Epi-Pen: ____ Yes _____ No
PARENT/GUARDIAN SIGNATURE: ____________________________________ DATE: ________________ Does your child have Health Insurance? Yes _____ No _____ NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents. For more information call 1-800-701-0710 or visit www.njfamilycare.org to apply online. If you would like us to release your name and address to the NJ FamilyCare Program, please sign below. Signature: ________________________ Printed Name: _________________________ Date: __________ Written consent required pursuant to 20 U.S.C. 1232g (b) (1) and 34C.F.R. 99.30 (b). I, grant permission for the nurse to share relevant health information with Morris Catholic High School faculty and staff to protect my child’s health and safety. _________________________________________________ ___________________________________ Parent/Guardian Signature Date