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?*

Date of Birth:*
Current Medication/s:

Emergency Contacts
Phone Contact:*
Other Contacts/Phone:

Type of Sickle Cell Anemia:  

Blood Type: Transfusion:*

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. *

Parent Signature