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School Based Health Program Sign Up

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Women’s Health Center Hattiesburg

Beaumont
- Beaumont Family Health Center
Brooklyn
- Brooklyn Family Health Center
Hattiesburg
Lumberton
- Lumberton Family Health Center
New Augusta
- New Augusta Family Health Center
Picayune
- Picayune Family Health Center
Seminary
- Seminary Family Health Center
Sumrall
- Sumrall Family Health Center

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Services › Specialty Services

More Specialty Services Services

Behavioral Health

Obstetrics/Gynecology

Optometry

School Based Health Program

School Based Health Program Sign Up

SeMRHI Form

Step 1 of 7

14%

School District
School District*

Student Information
Name*
First Middle Last
School*
Child's Birthday*
Social Security #*
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Email*
Are you Hispanic or Latino Descent?*
- Yes
- No
Student Race: (Choose all that apply)*
- American Indian/Alaska Native
- Asian
- Black/African American
- Native Hawaiian
- White/Causcasian
- Other Pacific Islander
- Unreported/Refused to report
Student Language: (Choose all that apply)*
- English
- Spanish
- Vietnamese
- French
- Creole
- Arabic
- Other
Parent(s)/Guardian(s):*
Name Date of Birth
Brothers:*
(Please type a number or type 0 to indicate none.)
Sisters:*
(Please type a number or type 0 to indicate none.)

Health History
When did your child last have a physical examination?
Name of Physician or Clinic:
Conditions: (Check all that apply)
- Asthma
- Anemia
- Injury
- Diabetes
- Seizures/Convulsions
- Heart Problems
- Vision Problems
- Frequent Ear Infections
- Hearing
- Sickle Cell Anemia
- Frequent Headaches
- ADHD
- Skin Problems
- Stomach Problems
- Problems Sleeping
- Frequent Colds/bad enough to miss school
- None
Drug Allergies

(Please list allergies or type none to indicate no allergies.)
Food Allergies

(Please list allergies or type none to indicate no allergies.)
Insects Allergies

(Please list allergies or type none to indicate no allergies.)
Other Health Problems: (Please Explain)
(Please type none to indicate no other health problems.)
Does your child take medication?
- Yes
- No
If Yes, List name of Medication(s)*
Has child been hospitalized for any reason since birth?
- Yes
- No
If Yes, Explain*
Is there anything more about this child's health that you think is important: (Please Explain)

Family History
Family Health History
- Diabetes
- Cancer
- High Blood Pressure
- Birth Defect
- Anemia
- Epilepsy
- Sickle Cell Anemia
- Heart Disease
- Learning Problems
- Mentally Disabled
- ADHD
- Other
- None
Diabetes - Indicate Relation to Child
Cancer - Indicate Relation to Child
High Blood Pressure - Indicate Relation to Child
Birth Defect - Indicate Relation to Child
Anemia - Indicate Relation to Child
Epilepsy - Indicate Relation to Child
Sickle Cell Anemia - Indicate Relation to Child*
Heart Disease - Indicate Relation to Child
Learning Problems - Indicate Relation to Child
Mentally Disabled - Indicate Relation to Child
ADHD - Indicate Relation to Child
Other - Explain and Indicate Relation to Child
Who should we contact in case of an emergency? (list 3 different people and telephone)
Name Relation to Child Phone Number

Required Insurance Information
The above named student has the following health care insurance coverage:
Does the above name student have any health insurance coverage including CHIP, Medicaid, or Private Insurance?
- Yes
- No
Medicaid #
CHIP #
Name of Health Insurance
Insurance Address
Street Address City State / Province / Region ZIP / Postal Code
Person who holds the Insurance (Subscriber)
First Middle Last
Social Security #
Date of Birth
Insurance ID #
Group #

Dental Insurance Information
The above named student has the following health care insurance coverage:
Does the above named student have any dental insurance?
- Yes
- No
Name of Dental Insurance
Person who holds the Insurance (Subscriber)
First Middle Last
Social Security #
Date of Birth
Insurance ID #
Group #
Employer Name:

By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Hattiesburg Public School District until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Covington County School District until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Forrest County School District until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Forrest County Agriculture High School until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Perry County School District until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
By completing the student health history form, I acknowledge that my child will receive the above services from Southeast Mississippi Rural Health Initiative, Inc. d/b/a Petal School District until they graduate, withdraw from school, or transfer to another school district. At any time I can opt-out of the program by contacting Southeast Mississippi Rural Health Initiative, Inc. at 601-545-8700.*
- Required
Signature*
I understand that my consent is required by Southeast Mississippi Rural Health, Inc., d/b/a PRVO Headstart, before my child can receive services. I hereby provide consent for the above named student to receive health care services in the area of vision, hearing, scoliosis, dental health, behavior/mental health and general health. I authorize the designated health and dental care professionals to provide necessary and/or advisable assessment and treatment such as dental sealants and cleanings for the above named student. Any third party coverage will be billed for payment. I give permission for necessary medical and dental test and treatments. I further release and hold harmless PRVO Headstart, and do give, grant, and release from any liability, costs, or loss which my child or I may sustain or incur now, or at any time in the future or as a direct or indirect result of any treatment, consultation or other action or inaction by PRVO Headstart.*
- Required
Signature*
Parent / Guardian Name*
Date*

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Southeast Mississippi Rural Health Initiative, Inc.
is an equal opportunity service provider. This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
©2016 Southeast Mississippi Rural Health Initiative, Inc. All rights reserved.

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Name	Date of Birth

Name	Relation to Child	Phone Number

SeMRHI Form

Step 1 of 7

School District

Student Information

Health History

Family History

Required Insurance Information

Dental Insurance Information