Team_____________

Frederick H. Tuttle Middle School
500 Dorset Street        So. Burlington, VT 05403
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Dear Parents:
    Welcome to another school year! Please take time now to complete this Emergency Form and Health Update for your child. This is one way we can assure your child's needs will be best served in an emergency situation. There may be times when a parent cannot be reached quickly, so please indicate names of two 'contact' people we could reach in such an emergency, along with their daytime phone number.
    Please note that these forms include permission to administer Advil and/or Tylenol for the current school year. These medications will NOT be given without this form signed and returned to the health office. If your child will be taking prescription medication or using an inhaler in school, please be sure to send in a physician's order for that medication.
   If you have any questions, please give me a call at the health office, 652-7106.        Thank you,
                                                                                                                                   Kary Towne, RN
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EMERGENCY CONTACT INFORMATION 2004-200

Student's Name____________________________    Grade_______    Birth Date_____________
Address __________________________________    Social Security Number _______________
Mother's Name ________________________________________________________________
Home Phone __________________________    Cell Phone/Pager _________________________
Work Phone __________________________    Place of Employment ______________________
Email ________________________________________________________________________
Father's Name _________________________________________________________________
Home Phone __________________________    Cell Phone/Pager _________________________
Work Phone __________________________    Place of Employment _______________________
Email _________________________________________________________________________
Child lives with __________________________________________________________________

List 2 people who will assume temporary care of your child if you cannot be reached:

1._____________________________________________________________________________
                 name                                                                        address                                                                day phone #

2. _____________________________________________________________________________
                name                                                                        address                                                                day phone #
In case of a serious accident or illness, I request that the school personnel contact me immediately. If unable to reach me, I hereby authorize the school officials to seek medical care for my child and make whatever arrangements may be necessary, while continuing to attempt to contact me.

___________________________                ______________________        _________________
   physician's name and phone #                                                Signature of parent/guardian                                     Date

If school mailings are to be sent to a second address (other then the one listed previously), please give the complete name and address below:

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

If there are individuals who are forbidden access to your child, please list information below. The school must have a copy of the court order on file in the front office. Please give a copy directly to an administrator.

_____________________________________________________________________________________
_____________________________________________________________________________________

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Health Office # 652-7106                                                                                     Team___________

Frederick H. Tuttle Middle School
500 Dorset Street    So. Burlington, VT 05403

2004-2005 HEALTH UPDATE

Student's Name_____________________________    Grade _________    Date ________________
Child's physician___________________________    Date of last physical exam __________________
Dentist _____________________ date last seen ______________ Orthodontist _________________

Yes  No    Does your child take medication? If yes, please list _________________________________
Yes  No    Does your child require medication while at school? (see medication policy)
                 List medications required during school hours ______________________________________
Yes  No    Does your child wear glasses or contact Lenses?
Yes  No    Does your child have hearing problems? If yes, followed by whom?______________
                 _________________________________________________________________________
Yes  No    Does your child have a seizure disorder? If yes, on medication? _________________
Yes  No    Has your child had any serious illness or injury within the past 5 years? If yes, please describe 
                 _________________________________________________________________________
Yes  No    Does your child have special dietary needs? If yes, explain _____________________
Yes  No    Does your child have allergies (food, medication, animals, etc.)? If an epi pen is required, 
                 please contact the nurse directly. Please describe allergies: ___________________
                 _________________________________________________________________________
Yes  No    Does your child have asthma? If yes, please contact nurse directly to discuss school treatment.
Yes  No    Does your child have a bee sting allergy? If yes, please describe the reaction and medical 
                 procedure to be followed. If an epi pen is required, please contact the nurse directly.
                 _________________________________________________________________________

INSURANCE:
Yes  No    My child is covered under an insurance policy
Yes  No    If you do not have health insurance, would you like to speak to the nurse about obtaining 
                 Medicaid or Dr. Dynasaur coverage?

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TYLENOL - ADVIL PERMISSION (We use generic brands at school)

Yes  No    Do you give permission for your child to have acetaminophen (Tylenol) or ibuprofen (Advil) 
                 at school if requested by the student and deemed appropriate by the school nurse?

IF YES PARENT/GUARDIAN SIGN HERE: __________________________________________
Special Instructions: _________________________________________________________________

If there is an other health information you wish to share, please do so below.

_________________________________________________________________________________
_________________________________________________________________________________

Yes  No     Do you have any health or personal concerns you wish to speak to the nurse about 
                  confidentially?

If yes,     Name _____________________________________________________________________
              Phone number ________________________ best time to call __________________________

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IMMUNIZATIONS:   If your child has received any of the immunizations required by law for school attendance within the past year, please forward this information directly to the school nurse.      

REMINDER: If your child will not be attending school, please call in on the attendance line - 652-7100