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 Female

Grade: Birthdate: Homeroom Teacher:

Parent/Guardian (Call 1st): Relationship to student:

Home # Work # Cell #

Parent/Guardian (Call 2nd): Relationship to student:

Home # Work # Cell #

Emergency contact names/numbers if parent listed above cannot be reached:
1. Name: Relationship:

Home # Work # Cell #

2. Name: Relationship:

Home # Work # Cell #

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:

Allergies/Hayfever (list below)	Bleeding/Clotting Disorder	Head Injury -Concussion	Orthopedic/Bone
Bee Sting/Insect Allergy (list below)	Cerebral Palsy	Headaches	Medication Allergies - Reaction (list below)
ADHD	Chickenpox	Hearing Loss	Psychological - Psychiatric Treatment
Anemia (include Sickle Cell)	Cystic Fibrosis	Heart Condition - Murmur	Scoliosis
Arthritis	Diabetes	Hypertension	Seizures
Asthma	Food Allergy (list below)	Lead Exposure	Skin Disorders
Bladder/Kidney Disease	Gastro-intestinal	Mononucleosis	Vision Loss/Correction

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:

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Covington High School

606 South Lexington Avenue, Covington, Virginia 24426 | Phone 540-965-1410 | Fax 540-965-5870

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