2007-2008

Student Health Center Enrollment Form

Grades K-8

Parents - Please complete and sign this enrollment form to give consent for your child to use the Student Health Center for one year.

Student name _____________________________________ Date of birth Gender: _____male _____female

School__________________________________________ Grade level ___________________ Student ID# ________________

Race: ____White ____Black ____Asian ____Native American/Alaskan native ____ Native Hawaiian/Pacific Islander

____Other race (Specify) _______________________ _____Two or more races (Specify) ________________________________

Are you Latino or Hispanic? _____yes _____no What country were you born in? ___________________________________

What is the primary language spoken in your home? _________________________

Social Security # ___________________ Address:_________________________________ Home phone:____________________

Parent work phone: _________________ Parent cell phone: _____________________ Student cell phone: ___________________

Parent(s) or legal guardian(s)________________________________ Address (if different than above) _______________________

Doctor/Health Care Provider _____________________________ Check here if you child does not have a health care provider:_____

Student Health Information

Please list below any known medical issues or special health concerns that will help us manage your child’s health needs.

Significant past illnesses, injury or hospitalizations __________________________________________________________________

____________________________________________________________________________________________________________

Allergies:_____________________________________ Asthma: _____yes _____no Cardiac disorder: _____yes _____no

Other physical, dental or mental health problems:____________________________________________________________________

Current medications:___________________________________________________________________________________________

Family Health History – Please check off where there is a family history of any of the following health conditions:

_____ Allergies _____ Diabetes _____ Immune disorder

_____ Asthma _____ Heart disease _____ Mental illness

_____ Alcohol or drug abuse _____ High blood pressure _____ Seizure disorder

_____ Cancer _____ High cholesterol _____ Tuberculosis

My child will need immunizations this year. _____ yes _____ no _____ don’t know

My child had his/her last physical exam within the last two years. _____ yes _____ no _____ don’t know

If your child is due for immunizations or a physical exam, would you like this done at school? _____ yes _____ no

Dental Health Information

Your dentist’s name _____________________________________ If you do not have a dentist, check here _____

Do you need help finding a dentist? ____yes ____no Does your child have dental pain (toothache)? _____yes _____no

When was the last time your child went to the dentist? ____within the last year ____over one year ago ____never

If your child is due for a dental cleaning, would you like this done at school? _____yes _____no

(See back)

Important insurance information below – please complete

Health Insurance Information

Do you have Medicaid/MaineCare coverage? _____ yes _____ no Do you have private insurance coverage? _____ yes _____ no

If employed, name of insured parent’s employer __________________________ Check here if you have no health insurance _____.

If you have MaineCare or private insurance, please provide us with a photocopy of your insurance card or fill-in the information on the blank sample card shown below. You may also have your child bring the card to us at the health center and we will make a copy.

Title of card __________________________

Insured person’s name _________________

Policy ID or Medicaid # ________________

Group # _____________________________

Physician ____________________________

Consent to Use the Student Health Center

I give permission for my child, ____________________________________________, to use the Student Health Center for one year which may include physical, dental or mental health services.

* I understand that my signature indicates that I have received a copy of the Notice of Privacy Practices.

* I understand that my signature also gives permission for the Student Health Center staff to access my child’s school health record and share pertinent health information with the school nurse or school social worker when it is deemed appropriate for treatment purposes.

* I understand that my signature allows for pertinent health and dental health information to be shared with my child’s doctor or dentist and with the mental health personnel from Community Counseling Center when and if my child is accessing those services.

* I understand that I may revoke this authorization at any time by written notice sent to the address below. Such revocation shall not affect any uses or disclosures permitted by your authorization while it was in effect.

Parent/guardian signature ____________________________________________________ Date

Print Name: _______________________________________ Relationship: _________________________

Please return this form to the Student Health Center or school nurse or mail/fax to:

City of Portland

Health & Human Services Department

Public Health Division

134 Congress Street

Portland, ME 04101

Fax 874-8920