_____ Sleep Walker _____ Scared of Dark _____ Anxiety Problems Need Assistance with: (circle all that apply) Feeding Dressing Bathing Other diagnoses, illnesses, and operations: ALLERGIES Food Name Reaction Medication Name Reaction Allergies Reaction EMERGENCY INFORMATION Can Pick-Up at Name Relation to Child Home Phone Mobile Phone Bus Stop Yes No Yes No Is child on regular medication? Yes No Please list all medications your is currently taking: Note: If YES, Administration of Medication Form must be filled out by a physician for EACH medication. This is a state requirement and the completion of the form allows the school to administer the prescribed medication. Parents must sign the form and a physician must complete the top of the form. A medication form must be completed for any prescription or long term over the counter medication during the school year. If a child is to carry their own inhaler and use as needed, a physician must authorize the self-administration of that medication. Medication must be in the original prescription bottle. Most pharmacies will give a second prescription bottle upon request to be sent to school. Please inform the Infirmary staff of any change in the child’s health so that they are better able to care for the student. The Health Services staff can be reached at 304-822-4831. Authorization for the Administration of Medication PHYSICIAN SIGNATURE REQUIRED Student’s Name: Date: Date of Birth: Parent’s Number: Parent’s Request/Approval for Administration of Medication at School
_____ Sleep Walker _____ Scared of Dark _____ Anxiety Problems Need Assistance with: (circle all that apply) Feeding Dressing Bathing Other diagnoses, illnesses, and operations: ALLERGIES Food Name Reaction Medication Name Reaction Allergies Reaction EMERGENCY INFORMATION Name Relation to Child Home Phone Mobile Phone Can Pick-Up at Bus Stop Yes No Yes No Is child on regular medication? Yes No Please list all medications your is currently taking: Note: If YES, Administration of Medication Form must be filled out by a physician for EACH medication. This is a state requirement and the completion of the form allows the school to administer the prescribed medication. Parents must sign the form and a physician must complete the top of the form. A medication form must be completed for any prescription or long term over the counter medication during the school year. If a child is to carry their own inhaler and use as needed, a physician must authorize the self-administration of that medication. Medication must be in the original prescription bottle. Most pharmacies will give a second prescription bottle upon request to be sent to school. Please inform the Infirmary staff of any change in the child’s health so that they are better able to care for the student. The Health Services staff can be reached at 304-822-4831. Authorization for the Administration of Medication PHYSICIAN SIGNATURE REQUIRED Student’s Name: Date: Date of Birth: Parent’s Number: Parent’s Request/Approval for Administration of Medication at School
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