Student Health and Waiver Form

STUDENT HEALTH AND WAIVER FORM

Student Information

Student Name:    Date of Birth:

Student ID:    Grade / Program:

Parent / Guardian Information

Relationship:    Primary Phone:

Relationship:    Phone:

Health Insurance & Physician

Policy / ID Number:    Subscriber Name:

Physician Phone:

Medical History & Allergies

Please indicate current or past medical conditions (check all that apply) and provide details where requested:

Asthma    Diabetes    Seizure disorder    Heart condition

Significant allergies    Mobility limitations    Other (describe below)

Does the student have a history of anaphylaxis requiring epinephrine?   Yes   No

Will student carry an auto-injectable epinephrine device while on campus or at events?   Yes   No

Medications

I authorize school personnel to administer the medication(s) listed above in accordance with written instructions provided by the parent/guardian and treating physician. Medication must be provided in original labeled container.

I authorize medication administration    I do not authorize medication administration

Immunizations

Provide dates of most recent immunizations where applicable:

Tdap:    MMR:    Varicella:

Activity Restrictions & Special Needs

Consent, Authorization, and Waiver

I certify that the information provided on this form is true and accurate to the best of my knowledge. In the event of a medical emergency, I authorize the institution and its employees, agents, and volunteers to seek and authorize emergency medical treatment for the student, including transportation to a medical facility, and to provide any medical information to treating medical personnel reasonably necessary for diagnosis and treatment.

By signing below I grant permission for designated staff to administer first aid and to arrange for emergency medical care, including but not limited to CPR, wound care, and administration of emergency medication (including epinephrine) when deemed necessary for the student's health and safety. I agree to be responsible for all costs incurred for such treatment and transportation.

I release and hold harmless the institution, its trustees, employees, agents, and volunteers from any liability for injuries, illnesses, or other incidents suffered by the student while participating in institution programs or while on institution premises, except to the extent caused by the institution's gross negligence or willful misconduct. I further agree to indemnify the institution for claims asserted by third parties arising from the student's actions where such actions are not caused by the institution.

I authorize the release of pertinent medical and health information about the student to institution personnel, emergency responders, and treating physicians as necessary to provide care. I understand that any information provided will be used only as needed for the student's safety and health management.

Media Release (Optional)

I grant permission for the student's image or likeness to be used for educational, informational, or promotional materials produced by the institution, provided no personally identifying information is disclosed without additional consent.    I do not grant permission

Acknowledgement

I acknowledge that I must notify the institution promptly of any changes in the student's health status, medications, or emergency contact information. I understand that failure to provide accurate information may affect the institution's ability to respond appropriately to a health emergency.

Sign Now