Wynne Public Schools P.O. Box 69 Wynne, Arkansas Seizure Care In The School

Size: px
Start display at page:

Download "Wynne Public Schools P.O. Box 69 Wynne, Arkansas Seizure Care In The School"

Transcription

1 Date_ Student_ Dear Parent/Guardian, Wynne Public Schools P.O. Box 69 Wynne, Arkansas Seizure Care In The School Grade Our records indicate that your child has a seizure disorder; good management of your child s condition is important for success at school. If your child requires emergency medication, please complete the attached packet. Return the clearly labeled medication(s) and any needed supplies to school. If your child does not require the use of emergency medication for seizures, please sign and return this form. Content of packet to be completed and returned to school nurse if emergency medication is needed. 1. Medication Administration Consent Form- Parent signs 2. Consent to Communicate with child s doctor- Parent signs 3. Seizure Action Plan-Doctor completes, Parent signs MY child ONLY has a history of Seizures and no longer takes medications. My child still takes daily seizure medication at home, but does not require emergency medications. Parent/Guardian: Date:_ If you have any questions, please call me at the number below. Your doctor may fax completed, signed forms to the school. Thank you, School Nurse District Primary Intermediate Jr. High Sr. High Jill Davis, RN Erin Oguin,RN Ashley Duncan,RN Rebecca Strasser, RN Carol Woodruff, RN (870) ext ext ext ext Fax (870) Fax (870) Fax (870) Fax (870)

2 SEIZURE ACTION PLAN FOR SCHOOL Student Name D.O.B. ID # Student School Teacher Picture Physician Phone: EMERGENCY CONTACTS Name Relationship Home # Work # Cell # Type of seizure: What does the seizure look like and how long does it usually last? Possible triggers that should be avoided: Does student need any special activity adaptations/protective equipment (e.g., helmet) at school? _ No _ Yes (explain) Is student allowed to participate in physical education and other activities? _ No _ Yes (explain) ARE MEDICATIONS NEEDED TO CONTROL THE SEIZURES? _ No _ Yes (List below the medications needed) MEDICATIONS AMOUNT TAKEN HOW OFTEN AND FOR WHAT SIGNS List medication needed at school (name, dosage/route, and frequency) Possible side effects that must be reported to parent or physician: IF GENERALIZED SEIZURE OCCURS: 1. If falling, assist student to floor, turn to side. 2. Loosen clothing at neck and waist; protect head from injury. 3. Clear away furniture and other objects from area. 4. Have another classroom adult direct students away from area. 5. TIME THE SEIZURE. 6. Allow seizure to run its course; DO NOT restrain or insert anything into student s mouth. Do not try to stop purposeless behavior. 7. During a general or grand mal seizure expect to see pale or bluish discoloration of the skin or lips. Expect to hear noisy breathing.

3 IF SMALLER SEIZURE OCCURS (e.g., lip smacking, behavior outburst, staring, twitching of mouth or hands) 1. Assist student to comfortable, sitting position. 2. Time the seizure. 3. Stay with student, speak gently, and help student get back on task following seizure. IF STUDENT EXHIBITS: 1. Absence of breathing or pulse. 2. Seizure of 10 minutes or greater duration. 3. Two or more consecutive (without a period of consciousness between) seizures which total 10 minutes or greater. 4. Continued unusually pale or bluish skin or lips or noisy breathing after the seizure has stopped. INTERVENTION: 1. Call START CPR for absent breathing or pulse. WHEN SEIZURE COMPLETED: 1. Reorient and assure student. a. Assist change into clean clothing if necessary. b. Allow student to sleep, as desired, after seizure. c. Allow student to eat, as desired, once fully alert and oriented. 2. A student recovering from a generalized seizure may manifest abnormal behavior such as incoherent speech, extreme restlessness, and confusion. This may last from five minutes to hours. 3. Inform parent immediately of seizure via telephone conversation if: a. Seizure is different from usual type or frequency or has not occurred at school in past month. b. Seizure meets criteria for 911 emergency call. c. Student has not returned to "normal self" after minutes. 4. Record seizure on Seizure Activity Log. If you want additional care given, describe action here: If symptoms are Give_ (medication/dose/route) Possible side effects_ Physician Signature Date Print Name Phone I want this plan implemented for my child,, in school. I hereby give my permission for exchange of confidential information contained in the record of my child between the nurse and physician and my signature is an informed consent to share this medical information with school staff as a need to know for academic success and emergency plan as determined by the nurse. Parent/Guardian Signature: Approved by School Nurse School Nurse Signature: Date: Date:

4 STUDENTS WITH SPECIAL HEALTH CARE NEEDS EMERGENCY PLAN NON-MEDICAL STAFF STUDENT NAME : DOB: TEACHER: RM/GRADE :_ PARENT/GUARDIAN: PREFERRED HOSPITAL: HOME PHONE #: WORK #: CELL #:_ EMERGENCY CONTACT: PHONE: OTHER PHONE:_ PHYSICIAN: PHYSICIAN TEL: PHYSICIAN FAX: STUDENT-SPECIFIC EMERGENCIES IF YOU SEE THIS DO THIS IF AN EMERGENCY OCCURS: 1. If the emergency is life-threatening, immediately call Stay with student or designate another adult to do so. 3. Call or designate someone to call the principal and/or school nurse. a. State who you are. b. State where you are. c. State problem. DOCUMENTATION OF STAFF TRAINING DATE: TRAINED BY: STAFF NAME:

5 STUDENTS TRANSPORTED WITH SPECIAL EQUIPMENT/NEEDS DRIVER/ATTENDANT INFORMATION SHEET STUDENT NAME : ADDRESS:_ PARENT/GUARDIAN: SCHOOL: TEACHER: AM ROUTE:PM ROUTE: HOME PHONE #: WORK #: CELL #:_ EMERGENCY CONTACT: PHONE: OTHER PHONE:_ PHYSICIAN: PHYSICIAN TEL: PHYSICIAN FAX: SPECIAL EQUIPMENT OR MEDICAL NEEDS ON BUS I.E. OXYGEN TANK, WHEELCHAIR, SEIZURES, GO-BAGS, ETC.- PLEASE INCLUDE SIZE AND DIMENSIONS OF ALL EQUIPMENT EMERGENCY BUS PLAN IF YOU SEE THIS DO THIS BEHAVIOR PLAN BEHAVIOR OR DISABILITY: INTERVENTION TO MANAGE THE BEHAVIOR/DISABILITY OTHER SPECIFIC NEEDS FOR SAFELY TRANSPORTING STUDENT DOCUMENTATION OF DRIVER/ATTENDANT TRAINING DATE DRIVER/ATTENDANT NAME NURSE/SCHOOL OFFICIAL

6 Wynne Public Schools P.O. Box 69 Wynne, Arkansas Consent To Share Information Student s Name Student s Date of Birth Student s School ID#_ I authorize personnel of the Wynne School District and personnel with any relevant agency or provider to access and exchange information in my or my child s files that may be beneficial in providing any or all needed services. I understand that I am giving my permission to share confidential information in an effort to better serve the needs of my family. Print Name of Parent/Legal Guardian Date Signature of Parent/Legal Guardian Date Nurse Signature Date

7 Wynne Public Schools P.O. Box 69 Wynne, Arkansas Medication Administration Consent Form Student Name DOB_Grade_HmRm Name of Medication Dosage_ Time to be Taken Ordering Physician Reason for Medication Other instructions Medication Procedures: 1. Only medications that are ordered and labeled to be taken with meals, at a specified time during school hours, or 4 or more times a day will be administered at school. Morning doses should be taken at home with a snack prior to coming to school. 2. Parent/guardian/designated adult must bring/sign in/count all medications, prescription and/or over-the-counter (OTC), to the nurse s office. Students are NOT permitted to have medication in their possession on the school bus or school campuses. EXCEPTION: EMERGENCY medications if consents/doctor orders are on file in nurse s office; these must be renewed annually. 3. All medications must be in the original container with the student s prescription label in place. OTC medications should have the student s name written on it and have the manufacturer s dose and directions included. I certify that at least one dose of this medication has previously been given (exception: emergency medication) with NO adverse reactions. Therefore, I give permission for the school to administer the above medication to my child according to the Board of Education procedure (see above). I will not hold the school staff responsible for any undesired reaction or effects which may occur from the medication. Only emergency medications will be sent on off-campus activities. I give permission for the school nurse to contact the prescribing doctor about medication(s) and to take a photograph of my child for identity purposes. Signature of Parent/Guardian Date Contact Number_

8 A.C.A , Act 1694, Rev 08/2011 Wynne Public Schools P.O. Box 69 Wynne, Arkansas EMERGENCY MEDICATION SELF-ADMINISTRATION CONSENT FORM P.O.BOX 69 * WYNNE, ARKANSAS * Primary , Intermediate , Jr. High , High School Student Name: Birth date: Parent/Guardian(print) Physician Name: Medication: Reason: (PRINT) (PRINT) The following MUST BE PROVIDED to the school by the parent/guardian to the school before the student will be allowed to carry and use emergency medication while at school, at an on-site school-sponsored activity, or at an off-campus school-sponsored activity. This is only valid for this academic school year at Wynne Schools. A new plan and consent must be obtained each school year or any re-entry into the Wynne Schools: PHYSICIAN -- As the prescribing physician, please verify the following for the above named student: _ Diagnosis(es): Name of medicine: Rx: Rx: Student needs emergency medication while at school, including any school-sponsored activity, due to a medical condition. _ Student CAN demonstrate the skill level, understands the treatment plan, has the responsibility necessary to use and selfadminister the prescribed medication _ I DO NOT RECOMMEND THAT THIS STUDENT CARRY OR SELF-ADMINISTER THIS EMERGENCY MEDICATION. Physician signature: Phone numbers: Date: PARENT -- As the parent/guardian of the above name student: _ I have discussed and agree with the treatment plan set up by the prescribing physician. _ I give permission for my child to carry and use emergency medicine while at school, at an on-site school-sponsored activity, or at an off-campus school-sponsored activity including any off-campus school activity. _ I agree and understand the school s student contract/agreement which my child has signed. _ I understand that I will supply my child s self-administered medicine, that it must have a current prescription label attached and be stored & transported in its original prescription-labeled container inside the student s backpack or purse. _ I understand my child must not share, transfer, unpack, show to others, or in any way divert their emergency medicine to any other student or person or shall be subject to disciplinary measures according to the school board of education policies for drug abuse. _ I understand that if my child does not demonstrate reliable behavior while carrying his/her emergency medicine, he/she will lose this privilege and the medication will be kept in the school Health Office. _ I will notify the school nurse or principal of any changes in the student s condition, medication or dosage, or changes in emergency contact information. No school employee, school agent, or school district shall be held liable for injury to a student caused by his/her use of self-administered medication. Parent/Guardian signature: Phone numbers: Date: STUDENT -- As the student, my responsibilities include: _ I understand the treatment plan documented by my prescribing physician. _ I can state when I need to use my emergency medication as documented by my doctor. _ I have demonstrated the skill necessary to use and self-administer my emergency medicine.

9 A.C.A , Act 1694, Rev 08/2011 _ I will immediately report to the school nurse (or designee) or principal, when I use my emergency medications so that my emergency emergency plan can be put into effect. _ I will carry my emergency medicine inside my backpack or purse in its original prescription-labeled container and will only take it out to self administer the medication during an emergency. _ I will not share, transfer, unpack, show to others, or in any way divert my emergency medicine to any other student or person, I shall be subject to disciplinary measures according to the school board of education policies for drug abuse. _ I understand that if I do not demonstrate reliable behavior while carrying my emergency medicine, I will lose this privilege and the medication will be kept in the school Health Office. Student signature: Phone number Date NURSE -- _ Received Emergency Action Plan from student s physician with MD signature. _ Physician signed MD section of this form. _ Student can demonstrate the skill level and verbalizes understanding of the treatment plan and correct administering procedure. _ Student signed above contract and verbalizes understanding. _ Signature completed in Parent section of this form and verbalizes understanding. _ Parent completed and signed authorization to release information form. _ Parent signed Medication Administration Consents. _ Student cannot demonstrate the skill level or verbalize understanding of the treatment plan and correct administering procedure (explain below).. Additional Comments: Nurse signature: Date:

To be completed by healthcare provider

To be completed by healthcare provider Allergy and Anaphylaxis Action Plan and Medication Orders Student s Name: D.O.B. Grade: School: Teacher: ALLERGY TO: Place child s photo here To be completed by healthcare provider History: Asthma: YES

More information

2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.

2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours. STUDENTS August 30, 2012 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine, EpiPen, EpiPen Jr.), and there

More information

2. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.

2. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours. STUDENTS June 4, 2014 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine Auto-Injection), and there is the

More information

Food / Insect Allergy Action Plan

Food / Insect Allergy Action Plan Food / Insect Allergy Action Plan 2017-2018 Student s Name: of Birth: Teacher Allergy to: Asthmatic: Yes* No Grade *Higher risk for severe reaction Step 1: Treatment Symptoms Give Checked Medication**

More information

1 st CONTACT in case of emergency/concern: Relationship: PHONE NUMBERS: Home: Cell: Work:

1 st CONTACT in case of emergency/concern: Relationship: PHONE NUMBERS: Home: Cell: Work: NORTH DAVIS PREPARATORY ACADEMY (NDPA) STUDENT MEDICAL FORM SCHOOL YEAR: 20 - ID #: ASPIRE: MEDS IN OFFICE: Student s Full Name: Age: Homeroom/Advisory: Grade: Parent/Guardian Full Name: Phone #: Please

More information

PARENT PACKET - SEIZURE

PARENT PACKET - SEIZURE School Year: Model Laboratory School SCHOOL HEALTH DIVISION (859) (859) PARENT PACKET - SEIZURE Dear Parent/Guardian: You have informed us that your student has a medical concern. Enclosed are the forms,

More information

Hampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms

Hampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms Newport News Public Schools Hampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms Developed by the Hampton Roads School Nurse Managers Parents/Guardians: Please complete Life

More information

ASSISTING STUDENTS WITH MEDICATIONS

ASSISTING STUDENTS WITH MEDICATIONS Administrative Rule ASSISTING STUDENTS WITH Code JLCD-R Issued 10/06 The needs of children who require medication during school hours to maintain and support their presence in school will be met in a safe

More information

The Arc of the St. Johns Summer Program

The Arc of the St. Johns Summer Program The Arc of the St. Johns Summer Program Phone 904.824.7249 Ext. 124; Fax 904.824.8063 lbolt@arcsj.org We are excited to offer you a summer program for your child! Listed are a few topics that we want you

More information

LOS ALAMITOS UNIFIED SCHOOL DISTRICT

LOS ALAMITOS UNIFIED SCHOOL DISTRICT LOS ALAMITOS UNIFIED SCHOOL DISTRICT Seizure Action Plan Student Name: DOB: School: Grade/Teacher: Parent/Guardian: Phone # Printed Name of Treating Neurologist: Treating Neurologist s Phone # Fax# Seizure

More information

ASSISTING STUDENTS WITH MEDICATIONS

ASSISTING STUDENTS WITH MEDICATIONS Administrative Rule ASSISTING STUDENTS WITH Code JLCD-R Issued DRAFT/17 The needs of children who require medication during school hours to maintain and support their presence in school will be met in

More information

Dear Parent/Guardian:

Dear Parent/Guardian: Dear Parent/Guardian: If it is necessary for your child to receive Epinephrine during school hours, school health policy requires that you provide a written request for the administration of the prescribed

More information

HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES

HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES 445 W. Main Street Clarksburg, WV 26301 (304) 326-7690 FAX (304) 326-7691 Dear Parent, Date Please complete the enclosed forms and return them to your

More information

Request for Severe Allergy Information

Request for Severe Allergy Information Request for Severe Allergy Information Dear Parent, You have disclosed that your child has a severe allergy. Wylie ISD requires additional information in order to take necessary precautions for your Child

More information

Valparaiso University Student Health Center lmmunotherapy Check List for Allergy patients

Valparaiso University Student Health Center lmmunotherapy Check List for Allergy patients Valparaiso University Student Health Center lmmunotherapy Check List for Allergy patients I have read and understood the lmmunotherapy policy and procedure. I have signed the Services Utilization Policy

More information

ASSISTING STUDENTS WITH MEDICATIONS AND THEIR HEALTHCARE NEEDS

ASSISTING STUDENTS WITH MEDICATIONS AND THEIR HEALTHCARE NEEDS Administrative Rule ASSISTING STUDENTS WITH MEDICATIONS AND THEIR HEALTHCARE NEEDS Code JLCD-R Issued 10/07 The needs of children who require medication during school hours to maintain and support presence

More information

Medication Administration in School

Medication Administration in School Medication Administration in School The parent/guardian of (Child s name) ask that the school nurse administer or principal/principal s designee observe selfadministration of the following medicine(s):

More information

Immunization Requirements as Mandated by the Georgia Department of Public Health

Immunization Requirements as Mandated by the Georgia Department of Public Health Dear Parents, As we prepare for the upcoming school year, it is time to begin preparing mandatory health forms for the upcoming school year. Our procedures closely align with other private schools in the

More information

2. Short term prescription medication and drugs (administered for less than two weeks):

2. Short term prescription medication and drugs (administered for less than two weeks): Medication Administration Procedure This is a companion document with Policy # 516 Student Medication To access the policy: click on Policies (under the District Information heading) The Licensed School

More information

Ogden City School District Allergy Health and Emergency Care Plan for School. School: Grade: School Year:

Ogden City School District Allergy Health and Emergency Care Plan for School. School: Grade: School Year: PARENTS: Please place student s picture here Ogden City School District Allergy Health and Emergency Care Plan for School Student Name: Student must avoid contact with known allergen. School staff must

More information

1.1 To provide guidelines for medication administration to students while at school.

1.1 To provide guidelines for medication administration to students while at school. Windsor-Essex Catholic District School Board NUMBER: Pr ST: 11 Section: Students PROCEDURE Pr ST: 11 Student Health Support (Including Medication Administration at School) EFFECTIVE: Oct. 26, 1999 AMENDED:

More information

Medication Administration Skill Checklist (to be accompanied by daily medication log for applicable students) 1 page

Medication Administration Skill Checklist (to be accompanied by daily medication log for applicable students) 1 page See the following pages for exhibits relating to medical treatment: Exhibit A: Exhibit B: Exhibit C: Exhibit D: Exhibit E: Medication Administration Request Form and Guidelines for Administration of Medication

More information

SEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE. Student Name: Current Date: Date of Birth: Grade:

SEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE. Student Name: Current Date: Date of Birth: Grade: SEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE Student Name: Current Date: Date of Birth: Grade: 1. Describe in detail what your child is allergic to: 2. How often does your child have a severe

More information

FROM THE DESK OF THE SCHOOL NURSE School Year

FROM THE DESK OF THE SCHOOL NURSE School Year FROM THE DESK OF THE SCHOOL NURSE School Year 2016-2107 Dear Parents, Our goal is to provide for the health and well being of your child while s/he is attending school. Please read this letter carefully,

More information

*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE*

*A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR TO ADMITTANCE* WASHINGTON ACADEMY STUDENT HEALTH INFORMATION PACKET SCHOOL NURSE: PHONE: 973-239-6555 Ext: 204 FAX: 973-239-6335 *A COPY OF YOUR CHILD S IMMUNIZATION RECORD MUST BE FORWARED TO THE HEALTH OFFICE PRIOR

More information

THE TEXAS GUIDE TO SCHOOL HEALTH PROGRAMS 251

THE TEXAS GUIDE TO SCHOOL HEALTH PROGRAMS 251 THE TEXAS GUIDE TO SCHOOL HEALTH PROGRAMS 251 Exhibit 1: Skills Checklist for Medication Administration Person trained: Position: Instructor: Type of Medication Administration (Oral, Topical etc.): (*See

More information

REQUEST FOR SELF-ADMINSTRATION OF MEDICATION AT SCHOOL (Only for Epi-Pen and Metered Dose Inhaler) School: Teacher: Grade:

REQUEST FOR SELF-ADMINSTRATION OF MEDICATION AT SCHOOL (Only for Epi-Pen and Metered Dose Inhaler) School: Teacher: Grade: REQUEST FOR SELF-ADMINSTRATION OF MEDICATION AT SCHOOL (Only for Epi-Pen and Metered Dose Inhaler) Student: Birth Date: School: Teacher: Grade: TO BE COMPLETED BY AUTHORIZED HEALTH CARE PROVIDER Medication

More information

4.35 STUDENT MEDICATIONS

4.35 STUDENT MEDICATIONS 4.35 STUDENT MEDICATIONS General Authority of School Nurses Regarding Student Medications School nurses are not permitted to diagnose medical conditions or prescribe medications, including over-thecounter

More information

TOPS Piano and Creative Writing Camp Registration Form Summer 2018

TOPS Piano and Creative Writing Camp Registration Form Summer 2018 TOPS Piano and Creative Writing Camp Registration Form Summer 2018 Returning Camper New Camper Camper s Name Email(s) Address City Zip code Home phone Work phone(s) Cell phone(s) Parent/Guardian name Please

More information

Also, you must acknowledge that you understand the following by signing and dating this sheet:

Also, you must acknowledge that you understand the following by signing and dating this sheet: To the parents of You have registered a child for one of our programs and indicated that he or she has a documented life threatening food or insect allergy or other severe allergic reaction that requires

More information

Policy Title: Administration of Medication by School Personnel Policy No:

Policy Title: Administration of Medication by School Personnel Policy No: Policy Title: Administration of Medication by School Personnel Policy No: 504.14 The Board of Trustees recognizes that students attending schools in St. Maries Joint School District No. 41 may be required

More information

ADMINISTRATIVE PROCEDURES

ADMINISTRATIVE PROCEDURES Batch #4, Redline Edits SHELTON SCHOOL DISTRICT ADMINISTRATIVE PROCEDURES Policy No. 3416P Series 3000 (Students) Page 1 of 8 PROCEDURE - MEDICATION AT SCHOOL Under normal circumstances prescribed or oral

More information

ADMINISTRATION OF MEDICATION BY DELEGATION

ADMINISTRATION OF MEDICATION BY DELEGATION ADMINISTRATION OF MEDICATION BY DELEGATION ROLE AND RESPONSIBILITY OF THE TEACHER TRAINING MANUAL Medication Training Manual Final 10-2-17 Page 1 of 17 MEDICATION ADMINISTRATION TRAINING OBJECTIVES UPON

More information

RECTAL DIAZEPAM MEDICATION ORDERS IN SCHOOL PURPOSE, INFORMATION, GUIDELINES AND SAMPLE PROCEDURE

RECTAL DIAZEPAM MEDICATION ORDERS IN SCHOOL PURPOSE, INFORMATION, GUIDELINES AND SAMPLE PROCEDURE RECTAL DIAZEPAM MEDICATION ORDERS IN SCHOOL PURPOSE, INFORMATION, GUIDELINES AND SAMPLE PROCEDURE PURPOSE: To ensure student safety when recta! diazepam (RD) is administered in the educational setting.

More information

Toronto District School Board

Toronto District School Board Toronto District School Board Operational Procedure PR.536 SCH Title: MEDICATION Adopted: June 28, 2000 Revised: October 23, 2007, October 11, 2003 (Replaces D.002: ) Authorization: 1.0 OBJECTIVE To establish

More information

Raleigh Parks and Recreation. Permission Form for Assisted Administration of Medication

Raleigh Parks and Recreation. Permission Form for Assisted Administration of Medication Raleigh Parks and Recreation Permission Form for Assisted Administration of Medication Parks and Recreation employees only administer medication to participants if: 1. The City of Raleigh Permission Form

More information

Five Rights of Medication

Five Rights of Medication Five Rights of Medication Lack of knowledge has been implicated in many medication errors; therefore, education about broadly stated goals and practices to safely administer medications is essential. Medication

More information

Guidelines for Medication Distribution

Guidelines for Medication Distribution STUDENTS Guidelines for Medication Distribution 09.2241 AP.1 STUDENT SELF-MEDICATION With the written permission of a licensed healthcare provider and approval by the Principal, students may be authorized

More information

MEDICATION MONITORING AND MANAGEMENT Procedures

MEDICATION MONITORING AND MANAGEMENT Procedures MEDICATION MONITORING AND MANAGEMENT Procedures Waiver Programs Purpose To support persons served in their own homes with their medication needs. Scope This procedure applies to all Waiver employees who

More information

MEDICATION ADMINISTRATION TRAINING FOR SCHOOL PERSONNEL SCHOOL HEALTH SERVICES

MEDICATION ADMINISTRATION TRAINING FOR SCHOOL PERSONNEL SCHOOL HEALTH SERVICES MEDICATION ADMINISTRATION TRAINING FOR SCHOOL PERSONNEL SCHOOL HEALTH SERVICES OVERVIEW This training is intended for non-nursing staff in the school setting who have been assigned to give medication at

More information

POLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS

POLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS POLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS The Board of Trustees of the Mountain Home School District recognizes that students attending the schools in this district

More information

Diane Kulas, LSW. Dear Parent/Guardian,

Diane Kulas, LSW. Dear Parent/Guardian, Dear Parent/Guardian, Thank you for your interest in Camp Chimaqua, an overnight bereavement camp, through Hospice & Community Care s Pathways Center for Grief & Loss. The camp will be held on June 9-11,

More information

EMERGENCY CONTACT INFORMATION LIST ALL OTHER ADULTS YOU AUTHORIZE CONNECT STAFF TO RELEASE YOUR CHILD TO:

EMERGENCY CONTACT INFORMATION LIST ALL OTHER ADULTS YOU AUTHORIZE CONNECT STAFF TO RELEASE YOUR CHILD TO: AFTER SCHOOL PROGRAM Fall Spring CHILD PERSONAL DATA SHEET Child s DOB Home Address City State Zip Gender School Enrolled in: : Employer Email : Employer Email Work APP Requested Work APP Requested EMERGENCY

More information

Mount Pleasant School Supporting Children with Medical Conditions

Mount Pleasant School Supporting Children with Medical Conditions Mount Pleasant School Supporting Children with Medical Conditions This document must be read in conjunction with Defence Instruction Notice for Health Provision in BFSAI. This school is an inclusive community

More information

General Use Epinephrine Program Policy and Procedures

General Use Epinephrine Program Policy and Procedures General Use Epinephrine Program Policy and Procedures Archdiocese of Baltimore Department of Catholic Schools Office of Risk Management 2016/2017 School Year General Use Epinephrine Program Introduction

More information

Administration of Oral Prescription Medication Procedure Page 1 of 6

Administration of Oral Prescription Medication Procedure Page 1 of 6 Page 1 of 6 RATIONALE: Hamilton-Wentworth District School Board is committed to ensuring the provision of plans, programs, and/or services that will enable students with health or medical needs to attend

More information

STUDENTS Any school employee authorized in writing by the school administrator or school principal:

STUDENTS Any school employee authorized in writing by the school administrator or school principal: Fremont School District No. 215 STUDENTS 3510 Student Medicines Assistance in Self Administration of Medicines to Students Any school employee authorized in writing by the school administrator or school

More information

At this time, Montessori Education Center will not administer Glucose monitoring, Glucagon, G-tube feeding or ileostomy bags.

At this time, Montessori Education Center will not administer Glucose monitoring, Glucagon, G-tube feeding or ileostomy bags. MONTESSORI EDUCATION CENTER Incidental Medical Services Plan of Operation February, 2016 All intermittent health care shall be provided by office staff of the Montessori Education Center including but

More information

SCHOOL DISTRICT #43 (COQUITLAM) MEDICAL ALERT FORMS FORM(S) MUST BE COMPLETED AT THE START OF EACH SCHOOL YEAR

SCHOOL DISTRICT #43 (COQUITLAM) MEDICAL ALERT FORMS FORM(S) MUST BE COMPLETED AT THE START OF EACH SCHOOL YEAR SCHOOL DISTRICT #43 (COQUITLAM) MEDICAL ALERT FORMS FORM(S) MUST BE COMPLETED AT THE START OF EACH SCHOOL YEAR Please read instructions below carefully. Feel free to contact your school if you need any

More information

ADMINISTRATION OF MEDICATION PROCEDURE

ADMINISTRATION OF MEDICATION PROCEDURE 1302.47 Safety practices. ADMINISTRATION OF MEDICATION PROCEDURE b) A program must develop and implement a system of management, including ongoing training, oversight, correction and continuous improvement

More information

Sara Merrill, LSW & Elaine Ostrum, LCSW. Dear Parent/Guardian,

Sara Merrill, LSW & Elaine Ostrum, LCSW. Dear Parent/Guardian, Dear Parent/Guardian, Thank you for your interest in Camp Mend A Heart, a day bereavement camp sponsored by the Pathways Center for Grief & Loss. Our goal is to help families learn how to grieve together

More information

Children s Residential Treatment Center Medical Intake Information

Children s Residential Treatment Center Medical Intake Information Children s Residential Treatment Center Medical Intake Information The following is required at/by intake: q Copy of Current Insurance Cards (Medical, Dental, or Medical Assistance) q Proof of Physical

More information

Medication Administration Packet

Medication Administration Packet Medication Administration Packet CHILD S INFORMATIONPRESCRIBER S INFORMATION Authorization to Give Medicine PAGE 1 TO BE COMPLETED BY PARENT/GUARDIAN / / Name of Facility/School Today s Date / / Name of

More information

Thanks to Anne C. Byrne, RN, Medical Monitor at Northwest Georgia Regional Hospital. This presentation was developed from one she designed for that

Thanks to Anne C. Byrne, RN, Medical Monitor at Northwest Georgia Regional Hospital. This presentation was developed from one she designed for that Thanks to Anne C. Byrne, RN, Medical Monitor at Northwest Georgia Regional Hospital. This presentation was developed from one she designed for that hospital. 1 2 3 Note that an actual variance occurs when

More information

Section 2 Medication Orders

Section 2 Medication Orders Section 2 Medication Orders 2-1 Objectives: 1. List/recognize the components of a complete medication order. 2. Transcribe orders onto the Medication Administration Record (MAR) correctly use proper abbreviations,

More information

MONTAGUE RESIDENTS MONTAGUE NEW STUDENT REGISTRATION

MONTAGUE RESIDENTS MONTAGUE NEW STUDENT REGISTRATION Patricia Romyns Assistant to the Chief School Administrator MONTAGUE RESIDENTS John W. Waycie Business Administrator/Bd. Secretary Christopher Gregory Assistant Principal MONTAGUE NEW STUDENT REGISTRATION

More information

After School Program ABBOT DOWNING SCHOOL BEAVER MEADOW SCHOOL

After School Program ABBOT DOWNING SCHOOL BEAVER MEADOW SCHOOL @ Y 21C Y@21C is a partnership between the 21st Century Community Learning Centers and the Concord Family YMCA. PLEASE NOTE: registration must be confirmed by the YMCA before your child can attend program.

More information

NOT SIGNED/INCLUDED as my student does not self-administer medicine

NOT SIGNED/INCLUDED as my student does not self-administer medicine 2017-18 School Year Hello, and welcome to Ridge Point High School Band and Guard! The attached forms help us manage and support the more than 170 members of the Band and Guard. Please sign and return all

More information

ADMINISTRATION OF MEDICINE

ADMINISTRATION OF MEDICINE ADMINISTRATION OF MEDICINE Contents Pages Policy Statement 1 Administering of Medicines during School Hours 1 2 Health Care Plans 2-3 Record Keeping 3 Educational Visits and Activities off-site 3 Refusing

More information

Kairos Retreat for Teens [SFK13] September 22, 23, 24 & 25 th, 2016

Kairos Retreat for Teens [SFK13] September 22, 23, 24 & 25 th, 2016 For Juniors & Seniors in High School What is Kairos? Kairos, which means Lord s Time, is a Christian experience of prayer and reflection, run by a team of adults and trained peer leaders. St. Francis de

More information

AN OVERVIEW OF THE NEWLY REVISED GUIDELINES FOR MEDICATION ADMINISTRATION IN KANSAS SCHOOLS, JUNE 2017

AN OVERVIEW OF THE NEWLY REVISED GUIDELINES FOR MEDICATION ADMINISTRATION IN KANSAS SCHOOLS, JUNE 2017 AN OVERVIEW OF THE NEWLY REVISED GUIDELINES FOR MEDICATION ADMINISTRATION IN KANSAS SCHOOLS, JUNE 2017 A COLLABORATIVE EFFORT OF LICENSED PROFESSIONAL REGISTERED NURSES FROM SCHOOL DISTRICTS AND PUBLIC

More information

NEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES

NEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES NEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES J - Students Administering Medication to Students JHCD DATED: August 8, 2018 SECTION: POLICY TITLE: FILE NO.: TABLE OF CONTENTS 1. PURPOSE

More information

TENNESSEE CODE ANNOTATED 2008 by The State of Tennessee Title 49 Education Chapter 5 Personnel Part 4 --Employment and Assignment of Personnel

TENNESSEE CODE ANNOTATED 2008 by The State of Tennessee Title 49 Education Chapter 5 Personnel Part 4 --Employment and Assignment of Personnel TENNESSEE CODE ANNOTATED 2008 by The State of Tennessee Title 49 Education Chapter 5 Personnel Part 4 --Employment and Assignment of Personnel Tenn. Code Ann. 49-5-415 (2008) 49-5-415. Assistance in self-administration

More information

The first or adjusted dose of medication shall be administered at home by the parent/guardian prior to delivery of medication to school/sacc.

The first or adjusted dose of medication shall be administered at home by the parent/guardian prior to delivery of medication to school/sacc. Regulation 757-4 August 30, 2012 Administering Medication I. It is the intent of the Prince William County Public Schools (PWCS) to assist parents/guardians when they are unable to come to school/school

More information

FIRST at Blue Ridge, Inc.

FIRST at Blue Ridge, Inc. FIRST at Blue Ridge, Inc. Application for Admission FIRST at Blue Ridge, Inc. 32 Knox Road Ridgecrest, NC 28770 www.firstinc.org Important For this application to be considered, All forms must be filled

More information

KILLEEN INDEPENDENT SCHOOL DISTRICT MEDICATION PROCEDURES FOR THE ELEMENTARY STUDENT

KILLEEN INDEPENDENT SCHOOL DISTRICT MEDICATION PROCEDURES FOR THE ELEMENTARY STUDENT KILLEEN INDEPENDENT SCHOOL DISTRICT MEDICATION PROCEDURES FOR THE ELEMENTARY STUDENT At times a student may have an illness/condition which does not prevent the student from attending school but which

More information

DATE ISSUED: 10/24/ of 5 LDU FFAC(LOCAL)-X

DATE ISSUED: 10/24/ of 5 LDU FFAC(LOCAL)-X Student Illness Accidents Involving Students Emergency Treatment Forms Standards for All Medications Administering Medication Exceptions Provided by Parent Procedures shall be established by the administration

More information

Kairos Retreat Policies & Permission Forms Bring home to Parents TODAY!

Kairos Retreat Policies & Permission Forms Bring home to Parents TODAY! Kairos Retreat Policies & Permission Forms Bring home to Parents TODAY! ***Please Read All Information Carefully**** Complete & return all forms (retain first and back page) to the Reception Desk Main

More information

Maryland Department of Health and Mental Hygiene Center for Healthy Homes and Community Services Youth Camps. Health Program

Maryland Department of Health and Mental Hygiene Center for Healthy Homes and Community Services Youth Camps. Health Program Maryland Department of Health and Mental Hygiene Center for Healthy Homes and Community Services Youth Camps Health Program Purpose The purpose of a written health program is to inform camp staff and volunteers

More information

Frank Augustus Miller Middle School. Color Guard Team

Frank Augustus Miller Middle School. Color Guard Team Frank Augustus Miller Middle School Color Guard Team 2017 2018 Frank A. Miller Middle School Color Guard 17925 Krameria Ave. Riverside CA 92504 (951) 789-8181 Beth Salyers Color Guard Advisor Dear Parents,

More information

CAMP CONNECT CHILD/TEEN APPLICATION

CAMP CONNECT CHILD/TEEN APPLICATION CAMP CONNECT - 2018 CHILD/TEEN APPLICATION Please check which date you would like your child to attend: June 25-28 August 6-9 of Application: Camper s Name: (Last) (First) (Middle) Home Address: City:

More information

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission:

Adventure Club. Before and After School Care Enrollment Packet. Before and After School Care Mission: Adventure Club Before and After School Care Enrollment Packet Before and After School Care Mission: Our before and after school care is designed to provide children with a safe, loving and exciting environment

More information

AIR FORCE CHILD AND YOUTH PROGRAMS MEDICATION ADMINISTRATION INSTRUCTIONAL GUIDE

AIR FORCE CHILD AND YOUTH PROGRAMS MEDICATION ADMINISTRATION INSTRUCTIONAL GUIDE AIR FORCE CHILD AND YOUTH PROGRAMS MEDICATION ADMINISTRATION INSTRUCTIONAL GUIDE September 2013 1. TRAINING OBJECTIVE: To assist CYP personnel (CYP staff and Family Child Care (FCC) providers) in understanding

More information

Penticton & District Community Resources Society. Child Care & Support Services. Medication Control and Monitoring Handbook

Penticton & District Community Resources Society. Child Care & Support Services. Medication Control and Monitoring Handbook Penticton & District Community Resources Society Child Care & Support Services Medication Control and Monitoring Handbook Revised Mar 2012 Table of Contents Table of Contents MEDICATION CONTROL AND MONITORING...

More information

Registration Form. School Name: Start Date: Grade:

Registration Form. School Name: Start Date: Grade: Registration Form Program Type: Afterschool Care Before Care School Name: Start Date: Grade: Child's Full Name: Address: City: Zip Code: Sex: Female Male Race: White Hispanic Black Other Hair Color: Eye

More information

Sample Policy Activity

Sample Policy Activity Sample Policy Activity NCCCHCA Medication Administration Policy Belief Statement Best Practice 1 : Families should check with the child's physician to see if a dose schedule can be arranged that does not

More information

RULES FOR STUDENT POSSESSION AND ADMINISTRATION OF ASTHMA, ALLERGY AND ANAPHYLAXIS MANAGEMENT MEDICATIONS OR OTHER PRESCRIPTION MEDICATIONS

RULES FOR STUDENT POSSESSION AND ADMINISTRATION OF ASTHMA, ALLERGY AND ANAPHYLAXIS MANAGEMENT MEDICATIONS OR OTHER PRESCRIPTION MEDICATIONS DEPARTMENT OF EDUCATION Colorado State Board of Education RULES FOR STUDENT POSSESSION AND ADMINISTRATION OF ASTHMA, ALLERGY AND ANAPHYLAXIS MANAGEMENT MEDICATIONS OR OTHER PRESCRIPTION MEDICATIONS 1 CCR

More information

Superintendent s Regulation 4400-R Exhibit 1

Superintendent s Regulation 4400-R Exhibit 1 Superintendent s Regulation 4400-R Exhibit 1 School Field Trip Planning Form Instructions All information on this form must be completed before presenting the form for approval to the Principal, School

More information

1. A. Prescription medication must be in an original container/vial issued by a pharmacy that indicates the following information:

1. A. Prescription medication must be in an original container/vial issued by a pharmacy that indicates the following information: 6003 1 School Administered Medication It is the policy of the Duncan Board of Education that if a student is required to take either prescription medication or non prescription/over the counter medication

More information

ROTARY DISTRICT 7930 ROTARY YOUTH LEADERSHIP AWARDS May 11-13, 2018 STUDENT APPLICATION

ROTARY DISTRICT 7930 ROTARY YOUTH LEADERSHIP AWARDS May 11-13, 2018 STUDENT APPLICATION Application Process ROTARY DISTRICT 7930 ROTARY YOUTH LEADERSHIP AWARDS May 11-13, 2018 STUDENT APPLICATION 1. Students in grades 10 or 11 (sophomore or junior) are eligible to attend RYLA. 2. STUDENTS--

More information

STUDENTS 3416 page 1 of 4 Administering Medicines to Students

STUDENTS 3416 page 1 of 4 Administering Medicines to Students 0 1 0 1 Livingston School District STUDENTS page 1 of Administering Medicines to Students Medication means prescribed drugs and medical devices that are controlled by the U.S. Food and Drug Administration

More information

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016

STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 The Clinic The Howard School 1192 Foster Street, NW Atlanta, Georgia 30318 Please complete this form and return with the other enrollment forms. Student

More information

Student/School Health Services SP 6.129

Student/School Health Services SP 6.129 POLICIES & PROCEDURES LAST REVISED: September 2017 (See revision history on last page.) Administration of Medication and /or Assisting with the Self-Administration of Medications As required by the State

More information

CAMP CO-OP 2018 Registration Packet

CAMP CO-OP 2018 Registration Packet CAMP CO-OP 2018 Registration Packet Registration Begins February 15, 2018 This summer day camp is designed for Charles County Public School students with significant cognitive delay who are receiving special

More information

Stratford Board of Education

Stratford Board of Education POLICY STATEMENT FOR ADMINISTRATION OF MEDICATIONS BY SCHOOL PERSONNEL It is the policy of the Stratford Board of Education to be in conformity with Section 10 212a 1 to 10 212a 7, as revised of the General

More information

MEDICATION ADMINISTRATION POLICY POLICY, PROCEDURES, & GUIDELINES FOR MEDICATION ADMINISTRATION II. PROCEDURES FOR MEDICATION ADMINISTRATION

MEDICATION ADMINISTRATION POLICY POLICY, PROCEDURES, & GUIDELINES FOR MEDICATION ADMINISTRATION II. PROCEDURES FOR MEDICATION ADMINISTRATION Insytt-ma-procedures 08-09; 02-17 page 1 of 7 MEDICATION ADMINISTRATION POLICY POLICY, PROCEDURES, & GUIDELINES F MEDICATION ADMINISTRATION II. PROCEDURES F MEDICATION ADMINISTRATION Procedures used for

More information

Welcome to Respite Relief

Welcome to Respite Relief Welcome to Respite Relief The Pueblo City-County Health Department has partnered with the Colorado State University Pueblo (CSUP), YMCA, and Pueblo Community College (PCC) to bring a respite care service

More information

$850* March 26- April 1. All-inclusive HBCU Tour. Register online at or at any of the monthly meetings.

$850* March 26- April 1. All-inclusive HBCU Tour. Register online at  or at any of the monthly meetings. Caring For Young Minds 2016 HBCU Tour March 26- April 1 $850* All-inclusive Luxury Motor Coach Meals Provided Marriott Hotels Well-Trained Chaperones Private Session with Admissions Onsite acceptance and

More information

Total Grace Achievers Academy Summer Camp Enrollment Application. Where kids can experience Life and Learn to Achieve

Total Grace Achievers Academy Summer Camp Enrollment Application. Where kids can experience Life and Learn to Achieve Total Grace Achievers Academy Summer Camp Enrollment Application Where kids can experience Life and Learn to Achieve Student Information Child s Name DOB Age Grade School: Street Address City State Zip

More information

Advanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA).

Advanced Practice Provider (APP): Nurse Practitioner (NP) or Physician s Assistant (PA). GEORGIA DEPARTMENT OF JUVENILE JUSTICE Applicability: { } All DJJ Staff { } Administration { } Community Services {x} Secure Facilities (RYDC and YDC) Transmittal # 17-15 Policy # 11.26 Related Standards

More information

FORM CHECKLIST. You must complete online registration at

FORM CHECKLIST. You must complete online registration at FORM CHECKLIST You must complete online registration at http://my.cherrycreekschools.org The following optional forms should be brought to Student Check-In on August 2 nd, or returned to the school office

More information

MANAGING STUDENTS MEDICATIONS AND EMERGENCY MEDICAL NEEDS NEPN Code: JLCD

MANAGING STUDENTS MEDICATIONS AND EMERGENCY MEDICAL NEEDS NEPN Code: JLCD MANAGING STUDENTS MEDICATIONS AND EMERGENCY MEDICAL NEEDS Authorization Forms for Parents and Physicians: JLCD-E (1) JLCD-E (1a) JLCD-E (2) JLCD-E (2a) JLCD-E (3) JLCD-E (4) JLCD-E (4a) JLCD-E (4b) Authorization

More information

2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA

2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA 2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA CONTACT INFORMATION Camper s Name: Grade entering Fall 2018: Gender: Female Male Not specified DOB: Age as of 1st day of camp: Address: City: Zip

More information

RETURNING STUDENT INFORMATION UPDATE

RETURNING STUDENT INFORMATION UPDATE ST. FRANCIS CATHOLIC SCHOOL Student Information Date: RETURNING STUDENT INFORMATION UPDATE Student Name Last First Middle I Nickname Birth Date Gender Grade Entering Birth Country Birth City Birth State

More information

First Aid Policy. This Policy should be used in conjunction with the DEECD Student Health reference.

First Aid Policy. This Policy should be used in conjunction with the DEECD Student Health reference. RATIONALE First Aid Policy UPDATED OCTOBER 29, 2014 All students and staff have the right to feel safe and well, and know that they will be attended to with due care when in need of first aid. AIMS To

More information

Summer Camp Registration

Summer Camp Registration _ YMCA of the Sandhills Summer Camp Registration Fayetteville YMCA 2717 Fort Bragg Rd. Fayetteville, NC 28303 (910) 426-9622 op.4 North YMCA 3725 Ramsey Street Fayetteville, NC 28311 (910) 426-9622 op.

More information

Applicant must have taken the ACT/SAT Test at least once and submit their scores.

Applicant must have taken the ACT/SAT Test at least once and submit their scores. HENDERSON STATE UNIVERSITY SUMMER INSTITUTE STUDENT INFORMATION SHEET Sunday, July 8-Thursday, July 12, 2018 Application deadline for ALL applications is Friday, June 4, 2018 ELIGIBILITY CRITERIA Applicant

More information

It is very important for you to ensure that your contact information is listed correctly on the registration form.

It is very important for you to ensure that your contact information is listed correctly on the registration form. Legacy Traditional School is proud to offer Legacy Kidscare (LKC), a non-licensed* program for before and after school childcare. LKC is open to any currently enrolled student. All services will be provided

More information

Parma High School Washington, DC Trip 2018

Parma High School Washington, DC Trip 2018 Parma High School Washington, DC Trip 2018 Dear Parents: Please find the attached Parents Approval Form Educational Trips Overnight / Out-of-State / Out-of-the-Country. Parents are asked to neatly print

More information

Timbuktu Academy-Summer Programs Southern University and A&M College Baton Rouge, LA

Timbuktu Academy-Summer Programs Southern University and A&M College Baton Rouge, LA Timbuktu Academy-Summer Programs Southern University and A&M College Baton Rouge, LA PROGRAM NAME: Getting Smarter at the Timbuktu Academy (GeSTA) Duration: Description: Four-weeks Orientation: Saturday,

More information