Covington City Public Schools
THE GREATER ALLEGHANY SCHOOL HEALTH PROJECT 2021 – 2022 Student Health History Form(Please complete entire form and submit as soon as possible.)
Student Health History Information
Please answer all questions. If any of your information changes during the year, please call the school office or send an email to the school to update information. Thank you.
Name:(Last) (First) (Ml) Sex: Male FemaleGrade: Birthdate: Homeroom Teacher:
Parent/Guardian (Call 1st): Relationship to student:
Home # Work # Cell #
Parent/Guardian (Call 2nd): Relationship to student:
Emergency contact names/numbers if parent listed above cannot be reached:1. Name: Relationship:
2. Name: Relationship:
Physician: Dentist:
Your child has the following health insurance (Please select all that apply) Private Medicaid FAMIS None
Please select all that apply to student:
Please give details/dates of all conditions marked above and other health conditions not listed.
Is your child taking medication (Prescription or Over-the-Counter)? Yes No If Yes, complete the following:
Name: Dosage: Reason for use:
If more than two, please list below:
*I give permission for my child to have the following medications if the nurse/school personnel feel it is necessary. I understand and accept that the Alleghany County/Covington School Boards, its employees, agents or designees are not responsible for any effects of the medication administered.
Tylenol: Yes No Benadryl: Yes No Cough Drops: Yes No
*I give permission for the nurse to share information with administration/faculty regarding health problems that may require emergency intervention. Yes No
*I give permission for my child to be transported to the hospital in the event of an emergency.Yes No
*I authorize my child's health care provider and designated provider of health care/school official to discuss my child's health concerns and/or exchange information You may withdraw your authorization at any time by contacting your child's school. Yes No
Please see school handbook in regard to medication at school and on the bus.
Parent/Guardian: Date: