Beaufort-Jasper Eoc Head Start

Individual School Health Plan Sickle Cell Anemia

Child's Last Name:*

Child's Middle Name:

Child's First Name:*

What program option are you registering for?*

Center:*

Date of Birth:*

School:

Teacher:

Current Medication/s:

Emergency Contacts

Parents:*

Phone Contact:*

Other Contacts/Phone:

Type of Sickle Cell Anemia:

Sickle Cell Anemia

Sickle Hemoglobin

Sickle Beta-Plus Thalassemia/Sickle Beta-Zero Thalassemia

Blood Type:	Transfusion:*
	Yes No

Special Needs during School Hours:

1. Resting Periods: As needed or Specify .
2. Unlimited access to fluids, especially during PE.
3. Unlimited bathroom pass.
4. Specify any needs for field trips:

5. Call parent when:

6. Call 911 when:

Other need to know information:

I confirm that I have read and understand this form. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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