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Camden City School District 201 N. Front Street, Camden, nj 08102

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Camden City School District 201 N. Front Street, Camden, nj 08102





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Camden City School District

201 N. Front Street, Camden, NJ 08102


HEALTH INFORMATION FORM: Complete the information below. If new to the Camden City School District, please provide your child’s health, medical, and immunization records and school entrance physical to the school nurse.


Student Name – please write name as it appears on the student’s birth certificate

Last Name:

First Name:


Middle Initial:

Date of Birth: (month/date/year)

_____ /_____/_________

Gender: ___M ___F

Grade Level:


Is the student currently on medication? ___ Y ___N

If yes, list any medications and condition:


Does the student have any allergies? ___ Y ___ N


Has there been an allergic reaction in the past year? __Y __N

If yes, list any allergies:


Date of last allergic reaction:

Has the student ever been hospitalized? ___ Y ___ N

If yes, list hospital, date, and condition:


Does the student have any chronic illness? (example: Diabetes, Asthma, seizures) ___ Y ___ N

If yes, explain:

Have there been any updates to the student’s immunizations/tetanus? ____Y ____N

If yes, list date and type of immunization:

Does the student have (check all that apply):

__ Braces __ Glasses __ Contact Lenses


Any other medical information you would like the school to be aware of? ___ Y ___ N

If yes, explain:

Do you give your permission for the school nurse to administer Tylenol (acetaminophen) to your child for an oral temperature elevation of 101F or above? The dose of the medication will reflect the child’s age and weight, and only one dose will be administered per day. ___ Y ___ N

If yes, check usual way Tylenol is given to your child:

__ Elixer (liquid) __ Chewable __ Tablet

Does this student have any health insurance including NJ FamilyCare/Medicaid, Medicare, private or other?

__ No my child does not have health insurance. You may release my name and address to the NJ FamilyCare Program to contact me about health insurance* __ Yes my child has health insurance

* Written consent required pursuant to 20 U.S.C. § 1232g(b)(1) and 34 C.F.R. 99.30(b).NJ FamilyCare provides free or low cost health insurance for uninsured children and certain low income parents. For more information visit www.njfamilycare.org to apply online or call 1-800-701-0710.



Primary Doctor Name:

Phone:

Date of last exam:

Dentist Name:

Phone:

Date of last exam:

Eye Doctor Name:

Phone:

Date of last exam:



I, the undersigned, hereby give permission for my child to receive the following medical attention as part of the school health program in Camden City public schools for the duration that my child is enrolled in a Camden City School: receive first aid; receive blood pressure, height and weight, vision and hearing screenings by the school nurse; and receive a scoliosis screening examination (strip to the waist) by the school nurse if my child is ages 10 to 18.
I also hereby authorize officials of Camden City School District to contact directly the person(s) named on the Parent/Guardian Emergency Contact Form and do authorize the School Nurse to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event that physicians, other persons named on this form, or parents/guardians cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of the aforesaid child, including transporting the child to the hospital. I will not hold the school district financially responsible for the emergency care and/or transportation for said child.

Parent/Guardian Name (Print): ______________________Signature: ____________________Date: ____/____/_______

For school use only: Received by (name/date): __________________ Entered in Genesis by (name/date): ___________________

Camden City School District

201 N. Front Street, Camden, NJ 08102




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