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It lists food and medication allergies, reactions, seizure and heart condition history, asthma and rescue inhaler use, and approval for the dorm staff to administer specified medications. It also gathers insurance coverage details and provides authorization and certification for assigning medical insurance benefits to the appropriate hospital billing office. Finally, it defines strict checkout rules, permitted release circumstances, identification requirements, weekend return timing, and accountability for costs when students are checked out.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/pine-ridge-school-residential-program-student-health-information-check-out-permission/158833/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/pine-ridge-school-residential-program-student-health-information-check-out-permission/158833.png","ImageObject",300,407,{"name":92,"@type":93},"Noah","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-21","2026-08-29",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What student health details does the form request?","Question",{"text":112,"@type":113},"It requests food allergies and reactions, medication allergies, seizure history, heart conditions, asthma and rescue inhaler use, whether Tylenol or Ibuprofen can be given, and any chronic long-term medication the student is taking.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What permissions are provided for medication administration?",{"text":117,"@type":113},"By completing the consent section, the parent/legal guardian gives permission for the dorm to administer medications to the student and indicates that the parent/guardian has read, understood, and agrees to the form’s medication authorization content.",{"name":119,"@type":110,"acceptedAnswer":120},"Under what conditions can a student be checked out from the dorm?",{"text":121,"@type":113},"A student can only be released to an immediate family member age 25 or older with written parental/guardian consent and administrative approval. The person must appear on campus with valid identification, and weekend checkout requires returning the student to the dorm by 10:00pm the evening before school resumes.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},158833,1788008542,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":129,"read_time":144},8796095462418,"https://ap-avatar.wpscdn.com/avatar/80000253c1241d02b47?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778826106357471780","US.Department of the interior  \nBureau of Indian Education  \nBureou-Opernaod Schoob  \nGirl's Dorm:605-867-5187  \nGrade:        \nBirth Date:            \nTribal Affiliation:                    \nTribal Enrollment\\#:                        \nSocial Security\\#:                      \nHome Telephone:                  \nDate Submitted:                    \n2023-2024 School Year  \nStudent Name:                                                                  \nWill student be 5 day dorm?      Willstudent be 7 day dorm?      \nMailing Address:                                                        \nPhysical Address:                                                        \n2.                                                                        \nBoy's Dorm:605-867-1385  \nMale:        \nFemale:      \nHome Agency:                \n_(Please Attach Copy)  \n(Please Attach Copy)  \nCell Phone:                    \nEmergency:                  \nStaff Initials:                    \n# Pine Ridge School Residential ProgramStudent Health Information\n\nStudent Name:                                                                                  \nList Food Allergies:                                  \nReaction:                                                                                                          \nMedication for reaction:(circle one/or more)Benadryl/Diphenhydramine/Epi-pen/other  \nList All Medication Allergies:                                                      \nMedication for reaction:(circle one/or more)Benadryl/Diphenhydramine/Epi-pen/other  \nSeizures:Yes No If yes,what kind of medication does he/she take?                    How Often?                                                                                            \nHeart Conditions:Yes No Medication(s):                                              \nHow Often:                                                                                          \nAsthma:Yes No Uses Rescue Inhaler?Yes NoMedication:                            \nCan he/she have Tylenol for pain?Yes No Can he/she have Ibuprofen for pain?Yes NoList any chronic medication/long term medication your child is taking:  \n\n| Medication   | Dose   | \\#of pills   |\n| --- | --- | --- |\n| Other medical conditions:   |  |  |\n\nWith my full consent,the Pine Ridge School Dorm has my permission to administrate medications to mychild.I (we),as Parent(s)/Legal Guardian(s)have read this consent form and fully understand and agreeto its content.  \n## Medical Insurance Information\n\nComplete the following:  \nPrint full name of student  \n## Social Security NumberDate of Birth\n\nIs your child covered under any medical or dental insurance?(Circle one)YESNOIf yes,please complete the following:  \nFor Private Insurance holders:  \n\n| Name of Insurance Company   | Policy Number   |\n| --- | --- |\n| Effective Date   | Group Number   |\n| For Medicare holders:   |  |\n\nClaim Number  \nEffective D  \n\n| I herebv assign to the HIS,Insurance benefits (if any)that I may have,pertaining to payment for  \u003Cbr>medical services and supplies furnished to mv child by HIS.I authorize payment of such benefits  \u003Cbr>directlv to HIS>I understand if anv pavments come directiv to me,that I must remit them to Indian  \u003Cbr>Service Hospital Business Office or other designated HIS Business Office.  \u003Cbr>I have been provided a copy of the HIS Notice of Privacy Practices(HIPPA)  \u003Cbr>I certify that the information given is true and accurate.   |\n| --- |\n\n\n| Printed Name of Parent/Guardian  \u003Cbr>Signature   |\n| --- |\n| Address  \u003Cbr>Phone Number where parent/guardian can be reached during the day:   |\n|  |\n\n## Permission for Student Check Out\n\nBureau of Indian Education(BIE),policy prohibits students from leaving campus with anyone other thanthe parent/guardian unless written consent is on file,and only under the following conditions:  \n※A student mav be released to immediate familv*onlv who are 25 vears or older:with writtenparental/guardian permission;and administrative approval.  \n","cbCainyFh1dmOCxS","https://ap.wps.com/l/cbCainyFh1dmOCxS","pdf",1811530,11,"English","# Pine Ridge School Residential Program\n## Student Health Information\n## Medical Insurance Information\n## Permission for Student Check Out","[{\"question\":\"What student health details does the form request?\",\"answer\":\"It requests food allergies and reactions, medication allergies, seizure history, heart conditions, asthma and rescue inhaler use, whether Tylenol or Ibuprofen can be given, and any chronic long-term medication the student is taking.\"},{\"question\":\"What permissions are provided for medication administration?\",\"answer\":\"By completing the consent section, the parent/legal guardian gives permission for the dorm to administer medications to the student and indicates that the parent/guardian has read, understood, and agrees to the form’s medication authorization content.\"},{\"question\":\"Under what conditions can a student be checked out from the dorm?\",\"answer\":\"A student can only be released to an immediate family member age 25 or older with written parental/guardian consent and administrative approval. The person must appear on campus with valid identification, and weekend checkout requires returning the student to the dorm by 10:00pm the evening before school resumes.\"}]","Pine Ridge School Residential Program - Student Health Information & Check-Out Permission | PDF",28]