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- HEA2600 Health Services Registration 2019

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HEA2600 Tucson Unified School District Revised:1/9/2019


□ CheckhereifyourchildDOESNOThaveanyhealthissues(signatbottom)
Doesyourchildhavealife‐threateningcondition?□ Yes□No
EmergencyCare:Incaseofseriousillnessorinjuryandaparent/guardiancannotbereached,Iconsentformychildtobetakentoa
hospital,byambulanceifnecessary,formedicalcare.TUSDwillnotberesponsibleforanycostsofsuchnotcoveredbyinsurance.

Parent/guardianisresponsiblefornotifyingtheschoolofneworexistinghealthconcernsandforprovidingtheschoolwithanymedicationorequipmentthatthestudentwill
requireduringtheschoolday.Contactthehealthofficetoobtainthecorrectproceduralforms.*Life‐threateningconditionssuchasanaphylaxis,asthma,diabetes,orother
conditionsrequireindividualhealthcareplans/actionsplans,medicationpermits,andstafftrainingpriortoyourchildattending.

□ Mychildwearsglassesorcontacts
Student’sName:___________________________________________ DateofBirth: Grade:_____
Last First Middle 
□ALLERGIES(*requiresanAllergyEmergencyPlanifinterventionisneededatschoolandamedicationpermitifmedicationwillbekeptinhealthoffice)
 □Food:□Bee/□ Insect:□Medication:□ Environmental:□Other:
Describetheallergicreactionandthetreatment:__________________________________________________________
□InjectableEpinephrineprescribed□MychildwillcarryInjectableEpinephrine&hasbeeninstructedonEpinephrineuse
□InjectableEpinephrinewillbekeptinHealthOffice* 

School Health Services
102 North Plumer Street
Tucson, Arizona 85719
SchoolYear 2019‐2020
HEALTHSERVICESREGISTRATIONPre‐K‐12
□ASTHMA(*requiresanAsthmaActionPlanifinterventionisneededatschoolandamedicationpermitifmedicationwillbekeptinhealthoffice)
Triggers: □Exercise □Environmental □Other:
□ Inhalerprescribed□Mychildwillcarryinhaler&hasbeeninstructedoninhaleruse □Inhalerwillbekeptinhealthoffice*
□Mychildwasdiagnosedwithasthmabutnolongerusesaninhaler‐dateoflastasthmaepisode:
□DIABETES(*aDiabetesCarePlanisrequiredforallstudentswithTypeIDiabetes‐pleasecontactthehealthofficestaffpriortothestartofschool)
□*TypeI(takesinsulin) □InsulinPump □Pen □Syringe □TypeII□Healthcareproviderplan



□EMOTIONAL/BEHAVIORAL/PSYCHOLOGICAL/DEVELOPMENTAL
□ADD/ADHD □Anxiety □Depression □OtherDiagnosis(es):_______________________________________
ReceivingTreatment
□Yes □ No



□SEIZURES(*pleasecontactthehealthofficestaffregardingaseizureactionplan)
Typeofseizure: □Dateoflastseizure:
□Diastatorotheremergencymedicationatschool*□ Controllermedicationathome
□OTHERMEDICALISSUES(ifyoucheckanyconditionsbelowpleaseexplaininspaceprovided)
□CerebralPalsy □HeartCondition□Concussion(date:) □Other:
□HEARING/VISION(otherthanglassesorcontacts)
□HearingImpairmentSpecify:_____________________________________ □VisualImpairmentSpecify:____________________________

□MEDICATION
□Medicationsatschool
Ifyourchildrequiresmedicationatschool,contacttheschoolhealthofficestaff.Requiresmedicationpermit.
Medicationtakenathome(Specify):
□MOBILITY/ACTIVITY*Contacthealthofficestaffifrestrictionorassistivedevice
□Mychildwillneedhelpwithactivitiesofdailylivingand/orhealthcareprocedures(*contacthealthofficestaff)
□Activityrestriction(Specify):□ Mychildusesanassistivedevice(Specify):_________________________________
HEA2600 Tucson Unified School District Revised:1/9/2019
Grade:_____
SCHOOLPROVIDEDOVERTHECOUNTERMEDICATIONS
Forstudentsonlyin6
th
–12
th
grades:
ForminorcomplaintsIauthorizethehealthofficestaff(maybeunlicensedindividualssuchashealthassistantsorofficestaff)togive:
Yes No‐Acetaminophen<100lbs=325mg,≥100lbs=650mg(genericTylenolforheadache,menstrualcramps,orotherminor
discomfort)
Yes No‐Ibuprofen<100lbs=200mg,≥100lbs=400mg(genericAdvilforheadache,menstrualcramps,orotherminordiscomfort)
PERMISSIONFORFLUORIDEMOUTHRINSEPROGRAMTOREDUCEDENTALCAVITIES
Forstudentsonlyin1
st
–5
th
grades
IWANTmychildtoparticipateintheArizonaDepartmentofHealthServicesfluoridemouthrinseprogram.IunderstandthatIcan
withdrawpermissionatanytimebynotifyingtheschoolhealthofficeinwriting.
IDONOTWANTmychildtoparticipateintheArizonaDepartmentofHealthServicesfluoridemouthrinseprogram.
Iwouldlikemoreinformationaboutdentalservicesavailableatschool. Pleasecontactme
General Dentistry 4 Kids https://www.gd4k.com/
Insurance
None Yes(NameofInsurance:____________________________________ AHCCCS TriCare)
Informationprovidedonthisformwillreplaceand/orupdateanyprevioushealthinformationreceivedwiththeexceptionofLife‐
ThreateningHealthConditions(contactnurseaboutremovingthisinformation).Itistheparent/guardianresponsibilitytonotifythe
healthofficeifanychangesoccurintheirchild’shealthstatus.
Parent/GuardianName(printed):_______________________
_
Parent/GuardianSignature:_______________________
_
Date:_______
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- HEA2600 Health Services Registration 2019

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Completed 18 July 2020

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