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: ____________
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