STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016
|
|
- Corey Miller
- 6 years ago
- Views:
Transcription
1 STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016 The Clinic The Howard School 1192 Foster Street, NW Atlanta, Georgia Please complete this form and return with the other enrollment forms. Student s Name: NOTE: All oral medication dosages will be calculated according to your child s weight. Generic medications may be substituted for name brands. PLEASE INITIAL EACH ITEM YOU APPROVE AND CROSS OUT THOSE YOU DO NOT WISH YOUR CHILD TO RECEIVE (Please do not check off) _ TYLENOL for headache, fever, or pain* initials IBUPROFEN for headaches, fever, or pain * MIDOL for menstrual cramps* BENADRYL, CLARITIN or CHLORPHENIRAMINE for allergic reaction to insect bites, stings, etc.* CALAMINE LOTION for insect bites, poison ivy, itchy skin rashes, etc. NEOSPORIN or BACTINE / ANTIBIOTIC or ANTI BACTERIAL CREAM for minor scrapes and scratches TUMS for indigestion* PEPTO-BISMOL for stomach aches or mild diarrhea* NON-DEET BUG REPELLENT for prevention of insect bites COUGH DROPS* CHILDREN S MUCINEX* KETOTIFEN FUMARATE EYE DROPTS OTC *Before oral medication is dispensed, the office will attempt to contact you. If we are unable to reach you by telephone, we will leave a message (if possible) to advise you as to what medication was administered and the time it was given. **Signature of Parent/Guardian **Signature of Parent/Guardian
2 **Signatures of BOTH parents/guardians of the above named child are required unless there is only one parent or legal guardian who has full custody of the above-named child.
3 MEDICATION INFORMATION FORM The Clinic The Howard School 1192 Foster Street, NW This Form Must Be Completed for ALL STUDENTS Atlanta, GA Phone Fax Please complete this form and return with other enrollment forms. Student s Name: Date of Birth: SECTION 1: TO BE COMPLETED, SIGNED AND DATED BY STUDENT S PHYSICIAN, IF STUDENT TAKES MEDICATION(S), INCLUDING HERBAL AND AS-NEEDED MEDICATION(S) AT HOME AND/OR AT SCHOOL PHYSICIAN S STATEMENT: Parent s Initial * Medication Both Generic and Common name Reason for Prescription Dosage in units, e.g., Side Effects or *Parent(s) MUST Initial mg and Frequency if school will administer Contraindications this Medication Physician s Signature, M.D. Date: Print Physician s Name: *Initials of BOTH parents/guardians of the above named child are required unless there is only one parent or legal guardian who has full custody of the above named child. Page 1 of 3
4 SECTION 2: TO BE COMPLETED, DATED AND SIGNED BY ALL PARENTS/GUARDIANS I give permission for my child to take this medication while in school or while participating in school activities away from the school site. I understand that (1) there is no liability on the part of the school, its personnel, or agents, and hereby release and waive any claims or actions against such persons or entity as the result of the administration of this medication to my child when the person administering the medication acts as an ordinarily reasonably prudent person would have acted under the same or similar circumstances; (2) this medication must be brought to the school only by a responsible adult; (3) this medication must be in its original labeled container; (4) this medication will be destroyed if it is not picked up within one week following the above stop date or one week after the close of the current school year, or when the medication prescription expires, whichever occurs first. I hereby authorize the exchange of medical information regarding my child s treatment plan between the physician and school health personnel. (Parents/Guardians MUST Check One Box and Sign Below) 1. My child takes medication(s) ONLY AT HOME, NOT AT SCHOOL. In the event my child is in your care at the time the medication(s) would have been due at home, for example, on a field trip, I release the school from any and all liability for administering the medication(s). 2. I request that The Howard School administer the ABOVE INITIALED MEDICATION(S) to my child according to the instructions contained in the physician s statement above. I release the school from any and all liability for administering the medication(s). 3. My child is NOT taking any medication(s), before, during or after school. **Signature of Parent/Guardian **Signature of Parent/Guardian **Signatures of BOTH parents/guardians of the above named child are required unless there is only one parent or legal guardian who has full custody of the above-named child. Page 2 of 3
5 Medication Information Form Instructions All students must have a completed form, dated within a year, on file at The Howard School. This is to reduce the risk of emergency treatment being delayed. Signatures of all parents/guardians are required on the form before submission. If your child is taking medication outside of school and/or if medication will be administered routinely while at school please note: The information on the medication form MUST match the pharmacy label on the bottle. Upon request, the pharmacy may dispense a prescription bottle specifically for school administration. There should be no more than one month s supply at school. If there are ANY CHANGES to the prescription, a new form MUST be submitted even if it is for a limited time period (ex. antibiotic). Please take a blank Medication Information Form to each appointment to obtain the physician s signature. Medications are to be delivered to school by an adult. Students should not have medications in their possession. Parental initials are required next to the medication information in section 1 if the medication is to be administered by the school. Signatures of parents/guardians and the physician are required before submitting the form. All medications should be collected prior to the end of the school year. Check Box # 1 if your child is taking medications outside of school. Check Box #2 if your child will be administered medications routinely while at school. Check Box #3 if your child is NOT taking ANY medications. Signatures of all parents/guardians are required before submission. An action plan, including medication administration details, needs to be revised annually for acute and chronic conditions. If you have any questions, please contact the school nurse or your prescribing physician. Colleen Ward, RN cward@howardschool.org Cell Phone ext 261 Fax Page 3 of 3
6 ANNUAL PHYSICAL EXAM & The Clinic HEALTH RECORD The Howard School FOR THE 1192 Foster Street, NW School Year Atlanta, GA Phone Fax ALL HOWARD SCHOOL STUDENTS MUST HAVE A PHYSICAL EXAM ANNUALLY. THE PHYSICAL EXAM ON FILE AT THE SCHOOL MUST BE WITHIN THE YEAR OF STARTING SCHOOL AND MUST BE KEPT CURRENT THEREAFTER. THE GEORGIA CERTIFICATE OF IMMUNIZATION is required by law for all students. All requirements must be met for school attendance. (Must include Hepatitis Series for children born after 01/01/92. NEW STUDENTS MUST ATTACH A CERTIFICATE OF IMMUNIZATION (FORM 3231) provided by your physicians office with this form annually. Student s Name: D.O.B.: Home Address: Home Phone: - - Father s Cell - - Mother s Cell - - ***** PHYSICIAN AND OR THEIR APRN OR PA-C ONLY TO COMPLETE BELOW THIS LINE PER GEORGIA CHAPTER, AMERICAN ACADEMY OF PEDIATRICS. ***** Physician s Name: Physician s Phone: - - Fax number: - - address - - PLEASE LIST ANY ALLERGIES (FOOD, DRUGS, INSECTS, ETC.): PLEASE LIST ANY PERTINENT/RECENT MEDICAL ISSUES: (for chronic illnesses, please provide a care plan written by the physician: i.e. asthma, severe allergies, epilepsy, cardiac history, etc.) SCHOOL PHYSICAL EXAMINATION (Name of Student) (MUST initial the sentence that applies): MAY participate fully in Physical Education and School Athletics. CANNOT fully participate in physical activities. Please include reasons why full participation in any school activity should be limited. Please indicate any special problems on the back of this form. was examined by me and found to be free of communicable diseases: YES NO was checked for scoliosis, scapula prominence, and shoulder tilt: YES NO Normal: YES NO was checked for vision: YES NO Test Date: / / Normal: YES NO was checked for hearing: YES NO Test Date: / / Normal: YES NO NOTE: THE HOWARD SCHOOL REQUIRES ANNUAL VISION AND HEARING SCREENING If any of the above is not normal, explain: Date of last Tetanus injection: / / (Please attach a 3231 form) Is student/family in therapy? If so, with whom? Phone: - - Type of therapy Routine medication: YES NO Prescribing Physician (if other than Pediatrician): Please complete medication form for all medications DATE OF EXAMINATION: / / PHYSICIAN S SIGNATURE:, M.D. REMINDER: Has the section relating to physical activity been completed? Revised 7/18/2013
7
8 CONSENT FOR EMERGENCY MEDICAL TREATMENT SUMMER 2016 Please complete this required form and return with the other enrollment forms. The Howard School 1192 Foster Street, NW Atlanta, GA If, in the opinion of a properly licensed and practicing physician (Student Name) needs medical or surgical services which require our/my pre-authorization or consent, we/i hereby authorize, appoints, and empower the School to act as Parent and furnish such consent on our/my behalf. We/I confirms that it is our/my desire that Student be furnished with such medical or surgical services as soon as reasonably possible after the need arises. We/I hereby release and hold the School harmless from any liability which might arise from the giving of such consent. We/I agree to reimburse the School for any medical expenditures made on Student s behalf. We/I further authorize the School to supply medical care as needed for the Student. This will include the administration of emergency medications and those prescribed by a licensed practitioner for the Student. We/I authorize the School to perform appropriate minor medical care, as determined by those School employees supervising the Student. We/I hereby release and hold the School harmless from any liability which might arise from the provision of such medical care. *Signature of Parent/Legal Guardian authorizing emergency treatment *Signature of Parent/Legal Guardian authorizing emergency treatment *Signatures of both parents/guardians of the above-named child are required unless there is only one parent or legal guardian who has full custody of the above-named child.
CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018
1 CAMP WASTAHI MEDICAL FORM DUE ON OR BEFORE JULY 1, 2018 CHECK LIST & INSTRUCTIONS FOR COMPLETING THIS FORM: This Medical Form is required EACH YEAR for every participant of Camp Wastahi. As a requirement
More informationAll-Star Adventure Program Summer 2016
Community- Faith-Business All-Star Adventure Program Summer 2016 Child s Name: Gender: M First Name Last Name please circle one Date of Birth: / / Ethnicity: Sexual Orientation: Custody Status: Parent/s:
More informationImmunization 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 informationCAMP 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 informationPRESCRIBING PHYSCIAN ONLY.
Return All Forms To: Administrative Address 985 Livingston Avenue North Brunswick, NJ 08902 Direct Phone/Fax: 732-737-8279 info@campjaycee.org Camp Address 223 Ziegler Road Effort, PA 18330 Phone: 570-629-3291
More informationFROM 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 informationFood / 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 informationTOPS 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 information2. 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 informationGuidelines 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 informationStudent General Information: Parent: Phone: Work Phone: Medical Information. You must attach a copy of front and back of current insurance card
Field Trip: Dates: Sponsor: Student General Information: Student Name: Date: DOB: Address: Parent: Phone: Work Phone: Parent: Phone: Work Phone: Medical Information Physician: Phone: Date of last Tetnus,
More informationDiane 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 information4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm
4-H Music Education Matters Summit Scholarship Application Open to all youth 8 th -12 th grade Scholarship Deadline: May 1, 2018 by 4:00pm Please type or print using black ink. Scholarship covers travel
More informationHanover Township Public Schools Memorial Junior School 61 Highland Avenue Whippany, New Jersey 07981
Dear Future 6 th Grade Parents: Hanover Township Public Schools Memorial Junior School 61 Highland Avenue Whippany, New Jersey 07981 May 9, 2014 I would like to thank you for attending last night s Fifth
More informationZooCrew Registration Packet Summer ZooCrew
Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6
More informationStudent General Information: Parent: Phone: Work Phone: Medical Information. You must attach a copy of front and back of current insurance card
Field Trip: Dates: Sponsor: Student General Information: Student Name: Date: DOB: Address: Parent: Phone: Work Phone: Parent: Phone: Work Phone: Medical Information Physician: Phone: Date of last Tetnus,
More information12111 NE First Street, Bellevue, Washington / P.O. Box 90010, Bellevue, Washington
Dear Parents/Guardians, January 18, 2017 Thank you for allowing your student to attend the SHOUT Experience. On Tuesday, March 28, 2017 the Bellevue School District will be hosting a leadership experience
More informationSara 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 informationMISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri
MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri APPLICANT NAME: (Last) (First) (Middle) ADDRESS: CITY: STATE: ZIP: EMAIL ADDRESS: AGE:
More information2018 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 informationCAMPER HEALTH HISTORY FORM1
CAMPER HEALTH HISTORY FORM1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Mail this form to the address below
More information*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**** Medical Information/ Emergency Contacts/ Insurance/ Consent ****
Arrival Departure Certification Level: **** Medical Information/ Emergency Contacts/ Insurance/ Consent **** Camper s Name: Birthdate: Age: Parent/Legal Guardian/Adult Leader Name: Day Time Phone: Evening
More informationFIRST BAPTIST FORNEY JUNE 22 nd TO JUNE 26 th FULL PAYMENT FOR ALL IS DUE BY JUNE 7TH
CAMP GAP 2015 FIRST BAPTIST FORNEY JUNE 22 nd TO JUNE 26 th EARLY RATE (March 22 nd May 3 rd ) $205 REGULAR RATE (May 4 th May 31 st ) $230 LATE RATE (June 1 st June 7 th ) $255 FULL PAYMENT FOR ALL IS
More informationApplication Part I & Part II Operation World Peace July 16 July 27, 2018
Application Part I & Part II Operation World Peace July 16 July 27, 2018 Students entering 6-11th grade are eligible for the summer program if they reside in the city of Rochester and are eligible to attend
More informationRETURNING 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 informationJanuary 27 th 7:30am- 7:00pm(ish)
A Little Bit of Faith, A Little Bit of Fun! January 27 th 7:30am- 7:00pm(ish) $25 for the Day! Teens are invited to our Winter Trip for a Mini-Retreat, visit the Gonzaga campus, and enjoy some Laser Tag
More informationStudent Summer Travel Application Iceland Parts A & B: Student Information & Emergency Contacts
Parts A & B: Student Information & Emergency Contacts 1. Student Name 2. I.D. Number Current Year in School 3. Email 4. Date of Birth 5. Names of parents/guardians 6. Address City, State, Zip 7. Home Telephone
More informationGEMS Parent/Guardian Forms
2017-18 GEMS Parent/Guardian Forms PARENTAL/GUARDIAN AFFIRMATION I, hereby give my permission to the Indianapolis Alumnae Chapter of Delta Sigma Theta Sorority, Incorporated for to participate in the Dr.
More informationSweet Pea s Learning Center
Sweet Pea s Learning Center STAFF USE ONLY Entrance / / 210 5 th Street PO Box 643 Trenton, GA 30752 706-657-2865 Child Enrollment Form PLEASE DO NOT LEAVE ANY BLANKS. STAFF USE ONLY Withdrawal / / Child
More informationST. CHARLES BORROMEO FOUNTAIN OF YOUTH YOUTH MINISTRY PROGRAM
YOUTH MINISTRY PROGRAM The St. Charles Borromeo Fountain of Youth is a unique Youth Ministry Program open to all young people in St. Charles Borromeo Church Parish in grades 5 12. Junior High Program is
More informationMANDATORY HEALTH FORMS
MANDATORY HEALTH FORMS All forms must be completed prior to enrollment Contact Information: School Nurse: nurse@grandriver.org Admissions: admissions@grandriver.org Checklist of Required Forms & Items:
More informationLETTER OF CONSENT AND RELEASE OF LIABILITY FOR THE DEPARTMENT OF NATIONAL DEFENCE/CANADIAN FORCES AND THE AIR CADET LEAGUE OF CANADA
LETTER OF CONSENT AND RELEASE OF LIABILITY FOR THE DEPARTMENT OF NATIONAL DEFENCE/CANADIAN FORCES AND THE AIR CADET LEAGUE OF CANADA To parents/guardians: please return this form filled and signed to 12
More informationNovember 17-19, 2017
NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration
More informationSample 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 informationCamp Like A Girl! Day Camp 2017
Lawrence County Girl Scouts Present Camp Like A Girl! Day Camp 2017 When: June 19 23, 2017 Where: Camp Agawam Who: All Girl Scouts K 12 Time: 9AM 3PM Daily Cost: $75 for week full of fun Registration Deadline:
More informationPolicy 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 informationSchool Based Health Consent for Services Grace Community Health Center, Inc.
School Based Health Consent for Services Grace Community Health Center, Inc. Please read carefully: In order for us to see your child in school based clinics, all pages of this form must be completed by
More informationThe 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 information2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults
2016 Health History and Enrollment for Sam Davis Youth Camp for Youth and Adults Complete this form in ink answering all questions. Please print legibly The parent/guardian and camper both must sign this
More informationCommunity Life Center
Community Life Center- 2018-2019 Page 2 of 6 MEGA SPORTS CAMP- Waiver & Release Forms Effective Dates: January 1, 2018 January 1, 2019 CHILD S INFORMATION Name Grade Age DOB Male/Female Nickname School:
More information2018 Counselor College
OHIO STATE UNIVERSITY EXTENSION 2018 Counselor College Canter s Cave 4-H Camp, Jackson, Ohio March 24 th @ 1:00 p.m. - March 25 th @ 10:30 a.m. Counselor College is open to any teen, 14-18 years of age,
More information16 Camp Alamisco
Theme: Following owing Jesus Camp Pastor: Jeremy Simpson YOUTH CAMP (for those who have completed grades 7 KIDS CAMP (for those who have JULY 13-16 16 (for those who have completed grades 7-12) for those
More information2018 SUMMER DAY CAMP ENROLLMENT PACKET
2018 SUMMER DAY CAMP ENROLLMENT PACKET Enrollment : Child s Full Name: Mother s Name: AGE: Birth : Home Father s Name: Gender: (Please circle) M F Mother s Father s Mother s Home Father s Home Employer:
More informationAttached you will find all necessary forms for registration. These forms may also be accessed at the link below:
Dr. Jillian Bohlen Animal and Dairy Science Department 425 Rhodes Center for Animal and Dairy Science Phone: 706-542-9108 E-mail: jfain@uga.edu April 26 th, 2018 4-H Agents, FFA Advisors, Youth Leaders
More informationAlso, 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 informationHealth Authority Abu Dhabi
Health Authority Abu Dhabi Document Title: HAAD Standards for administration of medication in schools Document Ref. Number: HAAD/AMDS/SD/1.0 Version 1.0 Approval Date: 13 August 2012 Effective Date: August
More informationParticipant is a: Student Cabin Leader Adult Chaperone Teacher/School Staff PARTICIPANT INFORMATION Name Male / Female/ Other Date of Birth Age
Registration and Health Form ** REQUIRED FOR ALL PARTICIPANTS** Please complete BOTH sides of this form legibly and in ink. Be sure to SIGN where indicated. Return to the participant s school. Please call
More informationSt. Joseph Parish Youth Ministry Registration 2018/19
St. Joseph Parish Youth Ministry Registration 2018/19 Please take a moment to register for this year s Youth Ministry program at St. Joseph, Colbert. St. Joseph Parish s Youth Ministry programs are open
More informationMonday, December 29 - Games Galore. Gaga Ball, Large Board Games, Pockey, Monkey Soccer, Predator/Prey Games
Winter Day Camp 2014 Grades K-5 Camp Frosty 8:00 a.m. to 5:00 p.m. $34 per day Before Care & After Care $10 per child, per session Before Care: 7:00 to 8:00 a.m. After Care: 5:00 to 6:00 p.m. Week 1: Monday,
More informationClermont-Hamilton Cloverbud Day Camp. Sunday, June 7, :00 a.m. 3:00 p.m. What is Cloverbud Day Camp? Activities.
Clermont-Hamilton Cloverbud Day Camp Sunday, June 7, 2015 10:00 a.m. 3:00 p.m. 4-H Camp Graham Craft Projects Camp Songs Field Games Story Time And much more! Activities Pool Games Circus Science Making
More informationCAMP DeWOLFE CAMPER HEALTH HISTORY FORM
To Parent(s)/Guardian(s): Please complete this health form and attach additional information if needed. Please ensure your child s health-care provider reviews the form and completes and signs their section
More informationAGE Is the student age 18 or older? (If YES, please skip to signature section below) p YES p NO
New York Summer music FeStivaL PERMISSION FORM This form must be emailed or faxed to NYSMF before your arrival. StudentName _ Festival Year AGE Is the student age 18 or older? (If YES, please skip to signature
More informationRETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria
RETURN COMPLETED FORMS AND FEE TO YOUR CHILD S SCIENCE TEACHER by Wednesday, March 4, 2015 Camp Parent Meeting, March 3rd, 6:30 pm, Cafeteria February, 2015 Dear Parents: After several years of 7 th graders
More informationPOLICY 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 informationAIR 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 informationNature Day Camp & Overnight Camp Permission Form
Nature Day Camp & Overnight Camp Permission Form This form must be completed and returned with appropriate documentation prior to the start of the camp. No camper will be allowed to participate in activities
More informationHealth History and Examination Form for Children, Youth and Adults Attending Camps
Health History and Examination Form for Children, Youth and Adults Attending Camps Suggested for resident camp use. Developed and approved by American Camping Association American Academy of Pediatrics
More information4-H Countywide Youth Lock-In Friend Registration Form
4-H Countywide Youth Lock-In Friend Registration Form Who?- Youth in Grades 4 th -8 th Where?- Kettle Moraine YMCA 1111 West Washington Street, West Bend When?- 8:00pm Saturday December 2 nd until 6:00am
More information2.. 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 informationSTUDENT PERSONNEL MEDICATION POLICY ADMINISTRATIVE PROCEDURES
STUDENT PERSONNEL MEDICATION POLICY ADMINISTRATIVE PROCEDURES Procedures for Implementation of Medication Administration A. All administration of medication must be under the general supervision of a Licensed
More informationASSISTING 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 information4-H Camp Tech. June Nationwide & Ohio Farm Bureau 4-H Center on
4-H Camp Tech June 13-14-15 Nationwide & Ohio Farm Bureau 4-H Center on the OSU campus You ll learn about science, technology, engineering and math through challenges and activities, including: Write code
More informationCAMP NEOFA. Northeast Odd Fellows Association Of the Independent Order of Odd Fellows
CAMP NEOFA Northeast Odd Fellows Association Of the Independent Order of Odd Fellows Member Jurisdictions: CONNECTICUT. MAINE. ATLANTIC PROVINCES. MASSACHUSETTS. NEW HAMPSHIRE. QUEBEC. RHODE ISLAND. VERMONT
More informationNOTE: WE REQUEST THAT PARISHES AND SCHOOLS DO NOT USE THE RALLY AS A SUBSTITUTE FOR A CONFIRMATION RETREAT.
M E M O TO: FROM: CYMs, DREs and Middle School/Jr. High Principals Clare Kolenda, Middle School Youth Rally Coordinator Brian Flynn, Office of Youth Ministry DATE: January, 2018 RE: Middle School Youth
More informationADMINISTRATIVE 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 informationMedication 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 informationNOT 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 informationHealth Clinic Policies:
Health Clinic Policies: Burris has one full time nurse on duty daily. The health of your student is our concern. Habits are formed in early childhood. These habits are important to growth, health, happiness
More information2018 RA Camp Discount Application
2018 RA Camp Discount Application Thank you for choosing Reston Association and placing your child(ren) in our care. The intent of the RA Camp Scholarship Program is to provide financial assistance to
More informationJohn de la Howe School PRE-PLACEMENT PHYSICAL EXAMINATION
PRE-PLACEMENT PHYSICAL EXAMINATION This form is required prior to admissions into either of the John de la Howe School programs. Please have this form completed by your family physician and fax it to (864)
More informationBOSTON COLLEGE BOYS BASKETBALL CAMP
BOSTON COLLEGE BOYS BASKETBALL CAMP 2015 APPLICATION Conte Forum 224 Camp phone: 617-552-3003 Dan McDermott, Director Chestnut Hill, MA 02467 MBB Office: 617-552-3006 Evan Librizzi, Assistant Director
More informationHIGHLAND MEDICAL INFORMATION FORM
HIGHLAND MEDICAL INFORMATION FORM TODAY S DATE: SESSION NAME SESSION DATE Having adequate information about your child is crucial to our ability to provide a supportive environment. We rely on you to tell
More informationAdventure 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 informationT Medications Monitoring Policy and Procedures
T1000 2014 Medications Monitoring Policy and Procedures ALL T1000 Parents, This notice applies to EVERY Scout even those NOT taking regular medication at campouts or other Troop/Patrol events and activities.
More informationParma 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 informationDear 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 informationLearn to create E-Textiles and Paper Circuitry A 2-day STEM workshop
Learn to create E-Textiles and Paper Circuitry A 2-day STEM workshop Thursday and Friday July 20-21, 2017 9:30 am 3 pm $35 materials fee This workshop is open to students who will be entering grades 5-7.
More informationASSISTING 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 information2018 SPORTS CAMP REGISTRATION FORM
2018 SPORTS CAMP REGISTRATION FORM CHILD NAME: Date of Birth Age T SHIRT SIZE: S M L XL WHAT SESSION(S) ARE YOU REGISTERING FOR (PLEASE CHECK): Jul 9 Jul 13 Jul 16 Jul 20 Jul 23 Jul 27 Aug 13 Aug 17 Aug
More informationSEVERE 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 informationHARRISON 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 informationUNIVERSAL CHILD HEALTH RECORD
UNIVERSAL CHILD HEALTH RECORD Endorsed by: SECTION I - TO BE COMPLETED BY PARENT(S) Child s Name (Last) (First) Gender Does Child Have Health Insurance? Yes No Male If Yes, Name of Child's Health Insurance
More informationWinter Hike. Games Movies. Canter s Cave 4-H Camp. And much more! January 28-29, Outdoor Activities
January 28-29, 2017 Canter s Cave 4-H Camp A fun-filled overnight adventure where you can relax and spend time with 4-H friends from across southeastern Ohio. WHEN: Saturday, January 28 (Registration from
More informationCamper Health Form Camp Y-Owasco
Camper Health Form Camp Y-Owasco Health History Forms must be filled out by a parent/guardian. Please complete all pages. Incomplete or unsigned forms will be returned to you. Please return the completed
More informationNC 4-H Youth Development Health History & Authorization Form
4-H Group / County: Year: (Must be updated each year) 4-H ers Name: Last Name First Name Middle Initial Birth Date / / Age as of Jan. 1 Gender: Female Male Email: Address: Street City State Zip Code Custodial
More informationMedication 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 information4-H Enrollment Form. Name of 4-H Group/Unit: Member Name: First Middle Last. Address: Street Address City State Zip Code
4-H Enrollment Form Name of 4-H Group/Unit: Year: Member Name: First Middle Last Address: Phone:( ) Email: County: Gender*: q Male q Female Date of Birth: Grade: School Attending: If re-enrolling in 4-H,
More informationChildren 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 informationCrossTi bars Julv 1& th --19 th
CrossTi bars Julv 1& th --19 th COST: $160 lids' ca p $60 Deposit to Reserve Spot Limited number of scholarships available (Must pay the deposit) Contact emily@waterlooroad.org for information Child's
More informationSTUDENTS 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 informationCamper Health History Form
Camper Health History Form Dates will attend camp: from to Camper name: (first) (middle) (last) Male Female Birth Date Age on arrival at camp: Camper Home Address: Street Address City State Zip Code Parent/guardian
More informationGlastonbury Family YMCA. CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET
2018 Glastonbury Family YMCA CAMP GLAWACKUS, CAMP LIGER and SPECIALTY CAMPS REGISTRATION PACKET CAMP LOCATION 30 High Street South Glastonbury, CT 06073 860-541-1812 STEP STEP one REGISTRATION Done online,
More informationRaleigh 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 informationDowners Grove Park District
Participant s Name Downers Grove Park District Summer Camp Forms 2018 Please check the camp(s) your child will attend to ensure we have emergency information at each camp: Adventure Camp (K-2: Lincoln
More information4-H Enrollment Form. Name of 4-H Group/Unit: Member Name: First Middle Last. Address: Street Address City State Zip Code
4-H Enrollment Form Name of 4-H Group/Unit: Year: Member Name: First Middle Last Address: Phone:( ) Email: County: Gender*: q Male q Female Date of Birth: Grade: School Attending: If re-enrolling in 4-H,
More informationKairos 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 informationVETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM
1 VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM When: Residential camp: June 24 (Sunday)-June 29 (Friday), 2018 Commuters: June 25 (Monday)-June 29, 2018 In order to get personal
More informationTo 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 informationRainbow Homes Travel Club Medical and Health History Form 2111 Adelpha Ave. Holt MI (517)
Rainbow Homes Travel Club Medical and Health History Form 2111 Adelpha Ave. Holt MI 48842 (517) 699-8454 rhclsprog@gmail.com PERSONAL Name: DOB: First Middle Last Preferred Seizures: Yes No Gender: Male
More information