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?
Early Head Start
Date of Birth:
Type of Sickle Cell Anemia:
Sickle Cell Anemia
Sickle Beta-Plus Thalassemia/Sickle Beta-Zero Thalassemia
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.
Please check any one sign.
By checking this option, I prefer to have the system electronically sign this form for me.