Enrollment Packet -Student Medical Information - Three Cords Academy

Medical Information for Student:

First

Middle

Last

Please fill out as much as you can. We can always adjust your enrollment packet after completion as needed.

List specific medical/health conditions

i.e. diabetic, asthmatic, ADD, ADHD, etc.

Please list all known allergies

i.e. specific foods, dyes or seasonal

Over the Counter Medications
A Medication Authorization Form must be sent in to accompany any type of medication. No over-the-counter medication will be given, i.e. Tylenol, ibuprofen, etc., unless it is from your student’s container, sent from home, and accompanied by the Medication Authorization Form.

Does the student take prescribed medications that will need to be administered during school hours?

Please list medications and routines.

Should my child suffer an injury or illness while in the care of Three Cords Academy and TCA is unable to contact me immediately, I authorize Three Cords Academy the right to secure medical attention and care for my child as may be necessary. I shall assume responsibility for payment of services. I agree to keep Three Cords Academy informed of changes in telephone numbers, etc. where I can be reached.

Student Physician Information

Student Physician Name

Phone

Student Health Insurance

Policy Number

Group Number

medical/health Please will

Reportable Communicable Diseases

Three Cords Academy is required to maintain the following agreement on file for every student.
1. The Georgia Department of Human Resources requires that a current immunization record be on file or a signed affidavit against such immunizations. No child shall continue enrollment in the school for more than 30 days without such evidence.
2. The parent/guardian(s) authorize the school to obtain immediate medical care for his/her child if an emergency occurs when the parent/guardian cannot be located immediately.
3. Parents are required to keep a child home if there is evidence of illness (temperature greater than 100ºF, vomiting, diarrhea, unexplained skin rash, etc.) Should illness develop during school, parent/guardian(s) will be contacted and asked to pick up the child immediately. Please help us protect the other children by responding promptly. When a child leaves school or stays home from school with an illness that includes a fever, diarrhea, or vomiting, the child must have a normal temperature, no diarrhea, or vomiting for 24 hours without medication before returning to school. There are no exceptions to this rule.
4. The parent/guardian(s) agree to inform the school within 24 hours or next business day after his/her child or any member of the immediate household has developed a reportable communicable disease, as defined on the communicable disease CDC website, here.
I understand and agree to adhere to the guidelines above and will continue to update TCA for the duration of my child’s enrollment at TCA.

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