STUDENT-OVER THE COUNTER MEDICATIONS FORM SUMMER 2016

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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 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

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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.

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