RANKIN COUNTY SCHOOL DISTRICT
STUDENT HEALTH RECORD
Student Name: Grade: Male ❏ Female ❏
Date of Birth: Age: Height (Feet / Inches): ’/ ” Weight (lbs):
Parent / Guardian: Address:
Cell #: Home #: Work#: E-Mail:
Medicaid #: Health Ins.:
Student’s Healthcare Provider: Phone #: Fax:
Student’s Medical History
ASTHMA
Does your child have asthma? Yes ❏ No ❏ If yes, mark one: Mild ❏ Moderate ❏ Severe ❏
An Asthma Plan is REQUIRED to be to be on file at the school for all students with asthma.
FOOD ALLERGIES
Does your child have food allergies? Yes ❏ No ❏ If yes, please list foods allergic to and reactions below.
LIFE THREATENING ALLERGIES TO INSECT BITES
Does your child have life threating allergies to insect bites? Yes ❏ No ❏ If yes, list insects:
All students with food and or insect allergies need an Allergy Plan on file at the school.
EPILEPSY / SEIZURES
Does your child have Epilepsy or seizures? Yes ❏ No ❏ If yes, your child needs an Epilepsy / Seizure Plan on file at the school.
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Updated 6/5/2020
DIABETES
Does your child have Diabetes? Yes ❏ No ❏ If yes, your child needs a Diabetes plan on file at the school.
Does your child have an insulin pump? Yes ❏ No ❏
EMERGENCY MEDICATIONS
Epipen: ❏ Rescue Inhaler: ❏ Diastat: ❏ Glucagon: ❏ None of These: ❏
DAILY MEDICATIONS
Is the student taking any daily prescription or OTC medication at home? Yes ❏ No ❏ If yes, please list below.
Will the student need to take medication daily at school? Yes ❏ No ❏
If your child has daily and / or emergency medications at school, each will need a Medication Consent Form (signed by a physician) to be on
file in the school office. You are responsible for supplying the medication.
OTHER
Is there anything else related to a diagnosed medical condition that you feel the school should know about your child?
CONSENT
The undersigned parent or guardian understands, acknowledges and agrees that state or county employed Region 8 health care support
service professionals / counselors will or may be providing counseling and / or health care services to all ages of RCSD students in addition
to the health care / counseling services for students traditionally provided by employees, nurses and counselors of the Rankin County
School District, and hereby consents to such proposed or provided services as may in the sole discretion of the school district or health care
providers be necessary or desirable while my child (children) is in the care of the school district.
Yes ❏ No ❏
For Middle / High School Students Only: I give consent for my child to participate in suicide prevention screening conducted by Region 8.
View Screener Here
Yes ❏ No ❏
Parent/Guardian Signature: Date:
Updated 6/5/2020
