Emergency contact name and phone # (other then parent)
PLEASE COMPLETE CAREFULLY: Student Height:
1. Describe medical conditions for which your child receives treatment (asthma, diabetes. allergies, etc.) you feel theschool/nurse should know about
2. Allergies to medications (please list)
5. Previous medical history (fracture or joint injuries)
Physician/Parent Authorization for Medication and Nursing CareHealth Office: Fort Lauderdale Phone 954-492-4170 Fax 954-492-4131 Boca Phone 561-852-2828 Fax 561-852-2835The health services at Pine Crest School are to provide immediate first aid, administer medication, and provide short-term care tostudents until a parent or designated Emergency Contact can pick up the student. A diagnosis cannot be made nor are there facilities forextended periods of bed rest. We ask your cooperation in keeping your child home if there is any question of illness.
Please Complete This Form Carefully and CompletelyDuring the school day medication is to be dispensed by the Health Office nurse. To be dispensed medication must be supplied by theparents in the original container. If a child uses insulin or an asthmatic inhaler and wants to carry this medication with him or her, aphysician order and a Permission to Carry and Self Medicate Form must be completed, signed and on file in the Health Office.
Does your child have any restrictions on his/her activities?
Does your child have any health needs which require the nurse's care during school hours?
Please contact the school nurse if the answer is yes to set up a health care plan.
PARENTAL PERMISSION FOR MEDICATION/TREATMENT
(TO BE COMPLETED BY THE STUDENT'S PARENT/GUARDIAN)
I grant the nurse, president or his/her designee the permission to assist or perform the administration of each medication or treatment/procedure for my childduring the school day including when he/she is away from school property for official school events.
NOTE: * Medications must be supplied in the original container. Ask the pharmacist to divide medication into two labeled containers.
* Only medications/treatments authorized by a physician may be administered by school personnel.
* It is your responsibility to notify the school when there is a change in medication/treatment regimen.
This grants permission to release information concerning treatment of my child (child's name)to the representative from Pine Crest School accompanying him/her and also to the school nurse. If, in the opinion of a properly licensed and practicing physician, myson/daughter needs medical or surgical services which require my/our authorization or consent before being supplied, I/we hereby authorize, appoint, and empower PineCrest Preparatory School, Inc. to act as my/our agent to furnish on my/our behalf such oral or written authorization as needed; it being my/our desire that my/ourson/daughter be furnished with medical or surgical services as soon as reasonably possible after the need arises. I understand this form will be used for medical treatmentduring all school related activities both on and off campus.
Signed by the Parent or Guardian who is legally authorized to make medical decisions on behalf of the student.
The foregoing instrument was acknowledged before me on this day of 2012, by (parent name)
who states that he/she has read the foregoing and that the factual statements contained therein are true and correct to the best of his/her knowledge. He/sheis personally known to me or did produce as identification.
(Print, type, or stamp Commissioned Name of Notary Public)
MEDICAL AUTHORIZATION FOR MEDICATION / TREATMENT
Please cross off medications the student MAY NOT have, and enter any additional medications needed.
The named medications are stocked in the Health Office. Attach additional signed physician orders to this sheet if necessary.
For contact dermatitis, itching, bug bites
For motion sickness, only for use on field trip
Other prescription medications to be administered at the school: please include a separate order (ie: Epi-pen, Xopenex, Inhalers, ADDMedication).
Name any health care procedures the student may independently monitor (ie: inhalers, insulin or glucose, epi-pen).
Health Office: 954-492-4170 - Fax: 954-492-4131
Health Office: 561-852-2828 - Fax: 561-852-2835
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