Dear parent/ guardian,

Student Name: ________________________________________
Grade: _____________

1. Within the past year has your child experienced a
5. Does your child take medication at home or in school on
serious illness or injury? (Circle answer) Yes No
a daily or as-needed basis? (Include inhaler if used). (Circle answer) Yes No
If yes, list medication, dose, and times given:
2. Within the past year has your child required any
ongoing treatment or surgery (Circle answer) Yes No
Has your child had a SERIOUS ALLERGIC reaction
CARE) to any of the following? (CIRCLE all that apply)
3. Does your child have any of the following? Circle all
Food Allergies: List symptoms and history of treatment.
that apply:
____________________________________________ Insect Stings: List symptoms and history of treatment.
____________________________________________ Seasonal/Environmental allergies: ______________ List on the reverse side of this form any additional health Did a doctor prescribe an EpiPen? Yes No
concerns or conditions that you wish to share. (If yes, provide an EpiPen for in-school use)
4. Does your child require any restrictions - especially in
7. I understand that the information provided on this form is physical education (PE)? (Circle answer) Yes No
confidential. I agree to allow the nurse to share this information with others who have a need to know to (Circle answer) Yes No

The school doctor has written standing orders for the following medications to be given by the school nurse, when needed:
CIRCLE EACH medication which may be given to your child. (Generic equivalent products may be provided).
CIRCLE EACH topical product below which may be applied to your child:
( ) Check here if you DO NOT wish to have any of the above medications administered to your child.
( ) My child is allergic to the following medication (s): __________________________________________________________

Please update the nurse with a written physician’s copy of immunizations as they are received during the year.
School Law requires students to provide proof of having had one Physical Examination between September 1 of their
sophomore year and June 1 of their junior year
Please initial your preference below:
( ) I would like my child to receive this examination in school, at no charge to me.
( ) I will have my child examined by my Family Physician. (Forms are available on-line at
Parent Signature ______________________________ Print Name________________________ Date ________________
I give permission for the school nurse to give my child the medications indicated above.



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