Visiting Student Medical Form

admissions-shadowVisit-studentMedical

Which Campus will your student be visiting?(Required)

Student Name(Required)

First Last

Student Date of Birth(Required)

Current Grade(Required)

Shadow Visit Date(Required)

Allergies(Required)

Food, drug, or environmental) and/or medical conditions(s) your child may have that we need to be aware of (i.e. asthma, diabetes, seizure history, food allergies, etc.

Emergency Medications(Required)

Medications that your child will be carrying with them to CHCA such as an Epi-Pen, inhaler, insulin, or anti-seizure medication.

My student is not experiencing any symptoms of illness such as vomiting, diarrhea, unexplained rash or persistent cough not related to asthma.(Required)

Yes, my student is not showing any symptoms

No, my student is showing symptoms

My student has not had a fever of 100 degrees or higher in the last 24 hours.(Required)

Yes, my student has not had a fever

No, my student has had a fever

Preferred Healthcare Provider(Required)

Healthcare Provider Phone(Required)

Preferred Dental Provider(Required)

Dental Provider Phone(Required)

Preferred Hospital

Please note: Hospital is at the discretion of EMS

Medical Consent(Required)

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by my preferred healthcare provider, or, in the event my preferred heathcare provider is not available, by another licensed healthcare provider; and (2) the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other healthcare providers, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Name of Adult Agreeing to the Medical Consent(Required)

By typing your name you are electronically signing this document.

Parent/Guardian #1(Required)

First Last

Phone(Required)

Parent/Guardian #2

First Last

Phone