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Pulaski county school system

Pulaski County School System
2010-2011 SCHOOL CLINIC PERMISSION FORM
Student Information:
Name _____________________________________________________ Homeroom ________________________
Called Name _________________________ Birth date ____________________
Parent / Guardian Information (Please circle person with whom the student resides)
Female Guardian Relationship: _________________________ Send mail to this address: _____
Name _____________________________________________________ Home # ____________________________
Address ___________________________________________________ City/State __________________________
Employer __________________________________________________ Work # ____________________________
Cell # _________________________________
Male Guardian Relationship: ___________________________ Send mail to this address: _____
Name _____________________________________________________ Home # ____________________________
Address ____________________________________________________ City/State __________________________
Employer ___________________________________________________ Work # ____________________________
Cell # _________________________________
Siblings: Please list full names of brothers & sisters (including their ages & schools attending)
___________________________________________________________________________________________
In the event a parent/guardian cannot be reached, the following people may be contacted with permission to pick
up my child from school:

1. ______________________________________ Relationship: _______________ Phone # ___________________
2. ______________________________________ Relationship: _______________ Phone # ___________________
3. ______________________________________ Relationship: _______________ Phone # ___________________
MEDICAL HISTORY
Allergies:(_____ None Known) ( ______ Yes, they are: ______________________________________)
Current Medications: ___________________________________________________________________________
Childhood Diseases
Chicken Pox
Diabetes
Hearing/Vision Impaired ___
Heart Condition
Scarlet Fever
Hypertension
Frequent Headaches
Student History
Nose Bleeds
Kidney/Bladder Problems ___
Stomach Problems
Seizures
Anxiety/Depression
Sickle Cell Anemia
ADD/ADHD
Other: ____________________________________

Basic first aid, Vision & Hearing Screenings and Scoliosis Screenings are provided by the by the school nurse. Due to safety
issues of the student, the only over the counter medications that will be kept and given, on a limited basis, at school are listed
below with reasons to be administered. Benadryl will be administered according to the manufacture’s recommendations based
upon age and/or weight. If other over the counter medications or prescription medications are needed, we will be glad to assist
with the correct form and medication, provided by the parent/guardian.

Name of Medication
Complaint / Problem
FOR PARENTAL CONSENT PLEASE SIGN: As parent/guardian of the above noted student, I give permission for
the school staff to administer basic first aid, the above checked medications, Vision & Hearing Screenings and Scoliosis
Screening to my child.
Parent/Guardian Signature: ______________________________________________ Date: _______________
Student Name:_________________________________________________ Grade: ______ Pulaski County School System
Guidelines for Administration of Medication
The administration of medication by school staff shall be permitted during the school day if it is not possible for the medication to be taken at home or if the prescribing physician specifically states a time during the school day at which the medication is to be given. In the event that medication must be administered to a student during school hours, the guidelines set forth should be followed. 1. Parent/Guardian must sign School Clinic Permission and Guidelines for Administration of Medication forms for any
services, including administration of medication, to be seen/treated by the school nurse.

2. Parent/Guardian must sign Authorization for Medication Administration before any long-term medications may be
administered or a
Short Term Medication Form before any short-term (no more than ten days) may be administered.
These forms must be completed at least once a school year or when any medication changes are made.

3. Short-term medications may be prescribed by the doctor and do not have to be given continuously throughout the
year or may be over the counter (OTC) medications for a short time only (no more than 10 days), per parent request.
Parental permission and administration information is required. This will be presented on a form entitled,
Short Term
Medication Form. These medications should be brought to the clinic by a parent or guardian and must be in the
original labeled container. The parent or guardian must provide the dosage and times to be given. OTC medications
will not be given without a physician’s order if the amount exceeds the standard dose per bottle. If medication is to be
given continuously throughout the year, an
Authorization of Medication Administration form must then be completed
and signed by a parent/guardian.

4. Long-term medications will be administered every day or as needed throughout the school year and must have an
order from the prescribing physician. These medications must also be delivered to the school clinic and an
Authorization for Administration of Medication form must be completed and signed by a parent.
5. Under no circumstances will any medication be given that is sent in any container, bag, wrapping, etc., other than
the original labeled container.

6. Any over the counter medications that are given on a daily basis for greater than ten school days must have a
physician’s order.

7. It is the responsibility of the parent/guardian to report to the school nurse any changes in pertinent information
regarding student health.

8. Parent/Guardian must immediately notify the school of any changes in medication.
9. All medication will be taken directly to the school nurse by the parent, guardian, or other responsible adult.
10. Students who require the use of a prescription Inhaler, Epi-Pen, or Insulin may carry their medication with them,
provided the appropriate authorization form is completed and signed by the student and parent/guardian.

11. Students may not carry over the counter or prescription medication on their person, purse or bag. All medication
brought to school must be taken to the clinic at the beginning of the school day. An exception will be made for cough
drops and throat lozenges.

I have read the above guidelines and agree with the conditions set forth by the Pulaski County School System. Parent/Guardian Signature: ________________________________________ Date: ____________

Source: http://www.pulaski.k12.ga.us/docs/2010-2011%20School%20Permission%20Form-0.pdf

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