HEA2600 Tucson Unified School District Revised:1/9/2019
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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.
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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.
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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
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EMOTIONAL/BEHAVIORAL/PSYCHOLOGICAL/DEVELOPMENTAL
ADD/ADHD Anxiety Depression OtherDiagnosis(es):_______________________________________
ReceivingTreatment
YesNo
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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:____________________________
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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):_______________________
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Parent/GuardianSignature:_______________________
_
Date:_______
click to sign
signature
click to edit
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