S
AN DIEGO UNIFIED SCHOOL DISTRICT
HEALTH INFORMATION EXCHANGE CONSENT
This form to be placed in all registration & annual registration update packets
Child's Name: Birthdate:
Last First Middle Month/Day/Year
School: Grade: Social Security #:
Phone No.: ( ) ( ) ( )
Area Code Home Area Code Work Area Code Cell
Physician's Name/Clinic: Telephone #: □ No Physician
Health Insurance Plan: □ No Health Plan
(If Medi-Cal, Covered CA, or another health plan, please write name of health plan)
□ My children do not have health insurance (example: Medi-Cal, Covered CA, private insurance) and I would like more
information. Please release my name, address, and telephone number to an authorized insurance enrollment worker.
HEALTH HISTORY: Indicate known Health Problems (give dates and details for all checked boxes in comment box below)
Asthma
Behavior/Emotional Problems i.e. ADHD
Kidney Disease
Seizure Disorder
Skin Conditions
□Ear Problem, Hearing Deficit
Operations, Fractures, Head Injury, Concussion
Other Health Information
State law requires that the parent inform the school if a child is receiving prescribed medication for a continuing health problem.
(California Education Code § 49480)
Medication: Dosage:
There are occasions when an over-the-counter (OTC) medication may be given to students six (6) years and older.
If you would like the school nurse or other trained staff to provide to your child ibuprofen, acetaminophen, calamine lotion and/or
antacids per district protocol please check: □ Yes □ No
T
his authorization expires at the end of each academic year and must be renewed annually.
PLEASE RETURN TOMORROW
Parent/Guardian Signature or Parent/Guardian Name (print) Date
Authorized Representative or Minor Student
Rev. 6/17 cm:kt
PS # 2059
