Ccf 455 Form – Fill Out and Use This PDF

Student Name:__________________________ Date of Birth:____ /____ / ____Home Phone: ( _____) _______________

LastFirstMI

Address:_____________________________________________________ Sex: ____ Student ID: ___________________

Number & StreetCityStateZIP

Emergency Information

Parents/Guardian Name(s):________________________________Work Phone: ( ____ ) __________ or ( ____ ) __________

Emergency Contact (if parents cannot be reached): _____________________________Phone Number: ( ____ ) _________

Physician’s Name: _____________________________________________________Phone Number: ( ____ ) _________

Who is responsible for medical payments?

Insurance

Individual

IF INSURED, Medical Insurance Company Name: ___________________________ Phone Number: ( ____ ) _________

Insurance Company Address: _________________________________________________________________________

Number & StreetCityStateZIP

Name of Primary Insured: ______________________________________________ Group #: ______________________

Note: Insurance coverage is not required for participation.

Brief Medical History

Special Health Concerns: ___________________________________________________________________________

Asthma:	yes	no	Heart Problem:	yes	no
Diabetes:	yes	no	Allergies:	yes	no
Seizures:	yes	no	Other: _______________________________________

	(Includes pregnancy, recent surgery,
Current Medications:	or other chronic conditions)
Medication:	Dosage per day:
______________________________________________	______________________________________________
______________________________________________	______________________________________________
______________________________________________	______________________________________________
______________________________________________	______________________________________________

Note: If your child is taking medication regularly, please bring a supply in a labeled container.

(Please Note: Prescription medication requires a current prescription label. Over-the-counter medication must be accompanied by an order from a licensed health care provider.)

_________________________________________________________________________________________________

I, the parent or legal guardian of ______________________________ (my child), authorize and direct the Clark County

School District to obtain medical care for my child in the event such care is reasonably necessary. I understand that, if possible, I will be contacted in the event my child requires medical attention. I grant to a licensed health care provider or accredited hos- pital permission to perform any reasonably necessary medical and/or surgical procedures that are essential for the treatment of my child and agree to be responsible for payment for such care. I release CCSD, its employees, and agents from any damages, liability, or loss resulting from the exercise of discretion in securing in good faith medical care for my child.

Parent or Guardian Signature:____________________________________________ Date: _______________________

DISTRIBUTION OF APPROVED COPIES: 1st Copy/White: advisor, 2nd Copy/Yellow: Activities Administrator, 3rd Copy/Pink: School Nurse 112