Microsoft word - letter for emergency form september 2013.doc

Concord Middle School
Community • Achievement • Lifelong Learning

835 Old Marlboro Road Concord, MA 01742 Phone: 978.318.1380 FAX: 978.318.1392 September 2013
Dear Parents and Guardians:
Please complete the Student Emergency Information Form on the reverse side of this letter for your child. Sign the
Information Form and return it to the homeroom teacher as soon as possible. It must be signed to make it an official
The following are some important Health Office guidelines you need to be aware of:
Medications: All medications to be taken during the school day must be brought to the School Nurse by a parent or
designated adult. Parent/guardian permission for administration must be in writing. In addition, the following requirements
must be met:
1. Over-the counter medications: These include cold medications, and pain relievers such as Naproxen (Aleve).
Physician authorization must be in writing (except for Acetaminophen, Ibuprofen, and cough drops, if indicated on the student emergency information form). All medications MUST be in manufacturer labeled bottles. No pills in plastic bags will be administered.
2. Prescription medications: All medications must be in a pharmacy labeled bottle. Ask the pharmacist to dispense a
duplicate bottle for use at school. For short-term antibiotics or medications to be given for less than two weeks, a parent/guardian note with signature and a properly labeled bottle is sufficient authorization. If the medication is to be administered for a longer time, physician authorization must be in writing.
Physicals: Please remember to send in your child’s Physical examination forms. If he/she wants to participate in any
interscholastic sports (school to school competition), and up-to-date physical is necessary and a copy must be in the school
Health Office in order for your child to participate. Please refer to the Parent/Student Handbook for additional information
regarding the above requirements, as well as other Health Office guidelines.
Physical Education Class Excuses: With a note from a parent, a student may be excused for one day of P.E. class because
of an injury or illness. If a longer time is warranted, a note from a Health Professional is required and is kept in the Student
Health Record in the building Health Office.
Thank you for your attention to these matters, which help to keep your student safe, healthy, and ready to learn. If you have
any questions please feel free to call:
Kate Bell, RN – Nurse Chair
Please complete the Student Emergency Information Form on page 2.
Please indicate in the (_) the order in which contact should be made ( )Mother/Guardian/Other In case of emergency, the school will attempt to contact parent/guardian before calling a student’s primary care provider (Physician). Your child will be transported by ambulance to an emergency care facility if necessary. ♦Name(s) of designated adult(s) who will assume responsibility and/or provide transportation if parent is unavailable: Please list medications your child is presently taking at home and/or at school: Please check all that applies to your child: Ο Allergies (Food, Insects, medication, environmental): Ο Heart Condition
Yes No I authorize the school nurse to administer Acetaminophen (Tylenol) to my child according to school
protocol for this school year.
__Yes __No I authorize the school nurse to administer Ibuprofen (Advil / Motrin) to my child according to school
protocol for this school year.
__Yes__No I authorize the school nurse to apply Bacitracin Ointment to my child based on their clinical assessment of the
__Yes__No I authorize the school nurse to administer over-the-counter cough drops to my child according to school
protocol for this school year.
Yes No I give permission to the school nurse to exchange information with my child’s health care providers for the
purpose of referral, diagnosis, and treatment for this school year.
I understand that I may revoke any of the above permissions by going to the school nurse and completing a new form.

Parent Signature



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