Health History - Canfield Local Schools

Ohio Department of Health • School and Adolescent Health
Health History
Date of birth
Sex
Student's name
0
Male
Female
Family Health History Please list allergies, heart problems, diabetes, cancer or other serious health conditions.
Father
Mother
Brothers and Sisters
Birth and Developmental History
0 No unusual birth or developmental history
EYes 1:1 No
Did the mother have any unusual physical or emotional illness during this pregnancy?
Did the infant have any sickness or problems?
Was infant born full term? 0 Yes 0 No
El Yes
El
No
Briefly explain illness or problems.
How does the child's development compare to other children, such as his or her brothers/sisters or playmates?
0
0 Advanced
0 Delayed
About the same
_Student Health Conditions
0
0 YES,my child receives regular medical/health care for the following conditions:
0 Allergies .
0
0 Asthma
0 Depression
0 ADD/AOHD
•
NO medical conditions
0 Seizure disorder
Diabetes
0 Sickle cell anemia
Ear problem/hearing difficulty
• Skin conditions
• Autism
• Emotional concerns
0 Behavior concerns
•
0 Birth/congenital malformations
0 Heart problems
0 Vision problems (glasses, contacts)
• Bone/muscle/joint problems
•
Hemophilia
0 Other
• Blood problems
0 juvenile arthritis
0 Other
0 Bowel/bladder problems
0 Lead poisoning
• Other
0 Cancer
0 Migraines
•
• Neuromuscular disorder
• Other
• Cystic fibrosis
0 Speech problems
0 Traumatic brain injury
Headaches
Other
Please explain any conditions above or any reasons for hospitalizations.
•
Please indicate any allergies your child may have.
Allergy type
• Bee/Insect
• Food
0 Medication
• Other
HEA 4240 8/06
Reaction
School restrictions or recommended actions
Health History
continued
Please list any prescription and over the counter medication that your child takes on a regular basis.
Medication and dose
Time
Reason
—
Do any health and/or medical conditions require school restrictions, modifications, and/or intervention?
0 Yes
1111 No
If YES, please explain.
Does the student require any special procedures and/or treatments for their health condition(s).
0 Yes
0 No
If YES, please explain.
.
Please Indicate any other information about your child's health or development that you think would be helpful for the school to know.
;OTM
completed by
•
Phone Number
EpiPen In School
YES
NI
NO
0
Inhaler In School
YES
El
NO
0
Relationship to student
Date
CANFIELD LOCAL SCHOOLS
NEW STUDENT BUSING INFORMATION
(Optional Form — Complete this ONLY if drop-off or pick-up address is different than home.)
To better meet the needs of working parents we will attempt to bus children to local daycares or sitters located
within the district.
These arrangements must be consistent Monday through Friday and remain in place the entire school
year.
Please provide the pick-up and drop-off address, if other than home, of your child. The address must be within
the school district. Deadline for submission is July 1, 201•.
Child's Name
Home Address
Pick-up Address
Drop-off Address
School
C.H. Campbell
Hilltop
E-Mail/ Internet Student Usage Policy
Canfield Local Schools
The following student Internet/e-mail online usage policy is to be signed by each
student and his/her parent(s) or legal guardian. This online service is provided by the
Mahoning County Board of Education through its Data Acquisition Site, hereafter cited as DAS,
and Canfield Local Schools. Any account inactive for 90 days is automatically disabled by OAS;
you can re-apply to activate it. During summer break all student accounts are disabled. Upon
signing this release form students are bound by its rules concerning proper online usage.
Upon request and approval you will be given an account for which you are completely
responsible. Your account usage is monitored and can be suspended upon violations detailed in
the guidelines which accompany this sheet.
For brevity we have included below the most important responsibilities you must be
aware of when using an account. Your first violation will result in the loss of your account for
30 school days; a second violation will result in the loss of your account for the remainder of
the school year.
1.
Your account is to be used only by you, whether at home or school. Cr. not give
your username and password to anyone, adult or student.
2.
The sending of any.inappropriate message (hateful speech, chain letters,
profanities, suggestive language/ pictures, or unkind words) is a violation of
this policy.
3.
It is aviolation of this policy to CHAT, or play interactive games without the
prior approval of your supervisor or teachers.
4.
It is a violation of this policy to download software, or games without the prior
approval of your supervisor o r teacher.
5.
Use of the World Wide Web without teachers supervision or permission is a
violation of this policy.
6.
It is aviolation of this policy to send personal e-mail during school hours unless
you have prior approval of a supervisor/teacher.
Student Name (Please Print)
Student Signature
Parent/Guardian Name (Please Print)
Parent/Guardian Signature
Date
Canfield Local Schools Media Release
School Year 20
-20
Form
Throughout the year, Canfield students participate in activities, events, or projects in which students may
be
photographed or videotaped. This includes, but is not limited to, school portraits, student projects, field trips, or
special events. If you consent to have your child's photograph used in any of the activities listed below, please
complete and sign this form.
Student Name:
.
Grade:
Teacher.
Circle one
I do, I do not, give permission for images of my child to appear in tha following:
1.)
In District Media —Including; but not limited to; bulletin boards, class-made books, or student
multimedia projects, school yearbook, Canfield Schools Cable Television, or school newsletter, school
website, district social media sites; students may be identified by first name only.
Circle one
I do,
2.)
I do not, give permission for images of my child to appear in the following:
Outside Media — Including, but not limited to: Town Crier, vindicator, etc.; students may be identified by
first and last name.
Parent or guardian signature:
Date: