Tel: (804) 769-3434 KING WILLIAM HIGH SCHOOL Fax: (804) 769-2430 80 CAVALIER DRIVE KING WILLIAM, VA 23086 STUDENT DATA FORM 2012-13
Child’s Legal Name:
*see principal if there is a concern with sharing this information. Student Resides with: Both Parents _____
Father/Male Guardian’s Name
Mother/Female Guardian’s Name
SchoolMessenger Contact Information Our automated parent information system, SchoolMessenger, calls your home with important news about school closings and delays, PTA meetings, special events, etc. In the event of a daytime weather emergency such as an early closing, we need daytime phone numbers to call. These can be parent work numbers, cell phone numbers, or your emergency contacts. Please list these numbers below. Note: the SchoolMessenger system can call only direct numbers. It can’t reach extensions. Use my Emergency Contacts for SchoolMessenger: Yes _____ or Use Contacts Below _____ SchoolMessenger daytime contact #1: Name:
SchoolMessenger daytime contact #2: Name:
Emergency Contacts (If Parents/Guardians Cannot Be Reached):
Please complete and sign back page of this form.
List all students who reside in this household and attend King William County Public Schools:
Please list ANY MEDICAL CONDITION THAT YOUR CHILD HAS: such as asthma, diabetes, seizures, heart condition, severe allergic reactions, skin condition, immuno-suppression, any medication taken regularly, nose bleeds, migraines, frequent headaches, anxiety disorder, etc. Please call the school nurse at 769-3434, ext. 606, to review this information and to have any needed medications in the clinic and plan on file.
Insurance and Physician Information: Do you have health insurance? Yes Physician’s Name:
Medical Permission: In the event of a medical/surgical emergency, every effort will be made to contact the parents or legal guardian. In the event that the parents/legal guardians cannot be contacted, we will need your permission to seek treatment for your child. This medical permission will apply to incidents occurring during school hours, on field trips, or during school sponsored activities. I hereby grant permission for my child to receive medically necessary emergency treatment including transportation to treatment: Child’s Name: , (do ___) (do not ___) authorize my child’s health care provider and designated provider of health care in the school setting to discuss my child’s health concerns and/or exchange information pertaining to this form.This authorization will be in place until or unless you withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record. Signature of Parent or Legal Guardian
Emergency Medication Permission: In case my child has an elevated body temperature greater than 101°F, and you cannot reach me or my emergency contacts, the school has permission to administer Acetaminophen (Tylenol) dosed on his/her body weight. I understand that I am still responsible to have my child picked up from school as soon as possible.
Medical Condition Notification: I grant permission for my child’s medical condition(s)/picture to be shared with essential King William County Schools personnel (such as bus drivers, teachers, etc.).
« PLASTIE MAMMAIRE D’AUGMENTATION PAR IMPLANTS PROTHETIQUES» Traitements médicaux : • Un traitement antalgique de base (PARACETAMOL) vous a été prescrit, il doit être pris de façon systématique pendant 10 jours. Un traitement antalgique plus puissant (TRAMADOL) est nécessaire pendant 48 heures ou plus suivant l’intensité des douleurs. • Un myorelaxant (TETRAZEPAM) est
MEDICAL HISTORY QUESTIONNAIRE □ Mr. □ Miss. □Mrs. □ Ms. □ Dr. IN CASE OF EMERGENCY, WE SHOULD NOTIFY __________________________________________ __________________________________________ Relationship: _______________________________ Date of Birth (Day/Month/Year): ___ / ___ / ____ Address (Home): ____________________________ Name of Family Doctor __________________________