School Based Health Program Sign Up SeMRHI Form Step 1 of 7 14% School DistrictSchool District*Covington County School DistrictForrest County School DistrictForrest County Agricultural High SchoolHattiesburg School DistrictPerry County School DistrictPetal School DistrictPRVO Headstart Student InformationName* First Middle Last School*Child's Birthday* Date Format: MM slash DD slash YYYY Social Security #Sex*MaleFemaleAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneWork PhoneEmail* Are you Hispanic or Latino Descent?*YesNoStudent 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):*NameDate 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 HistoryWhen did your child last have a physical examination? Date Format: MM slash DD slash YYYY 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?YesNoIf Yes, List name of Medication(s)*Has child been hospitalized for any reason since birth?YesNoIf Yes, Explain*Is there anything more about this child's health that you think is important: (Please Explain) Family HistoryFamily 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 ChildCancer - Indicate Relation to ChildHigh Blood Pressure - Indicate Relation to ChildBirth Defect - Indicate Relation to ChildAnemia - Indicate Relation to ChildEpilepsy - Indicate Relation to ChildSickle Cell Anemia - Indicate Relation to Child*Heart Disease - Indicate Relation to ChildLearning Problems - Indicate Relation to ChildMentally Disabled - Indicate Relation to ChildADHD - Indicate Relation to ChildOther - Explain and Indicate Relation to ChildWho should we contact in case of an emergency? (list 3 different people and telephone)NameRelation to ChildPhone Number Required Insurance InformationThe 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?YesNoMedicaid #CHIP #Name of Health InsuranceInsurance Address Street Address City State / Province / Region ZIP / Postal Code Person who holds the Insurance (Subscriber) First Middle Last Social Security #Date of Birth Date Format: MM slash DD slash YYYY Insurance ID #Group # Dental Insurance InformationThe above named student has the following health care insurance coverage:Does the above named student have any dental insurance?YesNoName of Dental InsurancePerson who holds the Insurance (Subscriber) First Middle Last Social Security #Date of Birth Date Format: MM slash DD slash YYYY 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* Date Format: MM slash DD slash YYYY