Microsoft word - mandatory forms booklet 2013-2014 2

Please Fill Out and Return
Forms by September 6th

REQUIRED FORMS FOR ALL STUDENTS:
1. *Emergency Contact Form
2. *Medical Information Form (both sides to be completed and signed by a
physician. This form was previously mailed to you in June.)
Students in JK-Grade 8 whose required Emergency Contact and Medical
Information Forms are not on file by September 6 will not be permitted to
participate in physical education, recess athletics, or field trips.

ADDITIONAL REQUIRED FORMS FOR NEW STUDENTS:
1. Department of Health New Admission Form Mailed to You in June
(Only if your child is a new student or has not yet turned 6) You must return the signed Emergency Contact and Medical Information forms
in addition to this form.

ADDITIONAL GRADE 7 STUDENTS REQUIREMENT:
1. In addition to the Emergency Contact Form and Medical Information Form,
Grade 7 students must provide the School Nurse with physician’s proof of
hepatitis inoculation.

OPTIONAL FORMS:
1. Prescription Medication Form
(To be signed by you and your physician for any prescription medications your child may need administered to them during the school day throughout the year.) 2 Lunch & Beverage Plan Form
In this booklet you will find both mandatory and optional forms for the upcoming school year.
Check the front cover to see which forms you need to fill out for your child(ren). Please fill out the
appropriate forms and permission slips) and return them to the front office by the first day of
school, Friday, September 6 (Wednesday September 4 for JK and K students). You have been
mailed one booklet of forms for each St. Luke’s student in your household. Please fill out one
form for each child. If you have already turned these medical forms in in June or over the summer
you do not need to fill them out again.
Also, note that your child cannot participate in PE, recess, athletics or field trips until all of
their mandatory forms have been completely filled out, signed by you and handed in.
Please contact Brenda Bramble ([email protected]) or Peggy Chen ([email protected]) in the front office with any questions regarding these forms. Sarah Cosentino Henry
Director of Administrative Services
PLEASE RETURN TO SCHOOL NURSE
MEDICAL INFORMATION FORM 2013-2014
Parents please complete and sign this page. A medical provider must sign and stamp this form.

Child’s Name:
List All Health Conditions/Medical and Surgical History (including Asthma, ADHD, etc.): OVER-THE-COUNTER (OTC) MEDICATION
No: Do not administer any OTC medication to my child. Yes: You may administer the following OTC medications:*
*No OTC medications will be administered without the signature and stamp of your medical provider in
the box below. Students are not permitted to keep medication in their possession. Please refer questions to the
School Nurse.
Signature
Parent/Guardian Relationship
MEDICAL APPROVAL
The student named above may participate fully in school activities and athletics. The student has medical approval for over-the-counter medication administration, following standard doses for weight and age. Medical Provider’s Name (Please Print) Provider’s Stamp Must Be Included Below Medical Provider’s Signature Date
MEDICAL PROVIDER PLEASE ATTACH PHYSICAL AND IMMUNIZATIONS TO THIS FORM.

PESTICIDE NOTIFICATION REQUEST
(Optional per pesticide letter included in ‘Welcome Packet’) Please consider this my formal request to be placed on the list to receive those notices and information required by pesticide notification laws. By signing this I acknowledge that I will receive this notice via email. _______________________________________________________________________________ St. Luke's School
EMERGENCY CONTACT INFORMATION FORM 2013-2014
This form must be completed every year. Each student must have the current form in his/her file in order to attend school.

Child’s
Parent/Guardian [1]- Please specify relationship
Parent/Guardian [2]- Please specify relationship
If parents are divorced or separated, whom should we contact first: Parent 1 ( ) Parent 2 ( ) Both ( ) Daytime Caretaker (if other than parent)/ Person authorized to regularly pickup your child at the end of the school
day.

Name:
Please list below three people we may contact in case of an emergency if none of the above are available. Please
remember that one contact person should be someone who lives in the neighborhood or is readily available and one
must be an out of town contact (outside the limits of New York City and its boroughs).
CONSENT FOR EMERGENCY MEDICAL TREATMENT
In the event that the child's parents are not available, I authorize the St. Luke’s School nurse and delegated staff to obtain emergency medical treatment for my child. I expect family and/or contact individuals to be notified as soon as possible regarding emergency interventions. I permit the nurse and staff to care for my child if he/she becomes ill during the school year. I permit the nurse to contact my child’s health care providers for medical instructions, health form updates and to report a medical/injury occurrence. Signature of Parent/Guardian Relationship
PARENT AND PROVIDER AUTHORIZATION FOR ADMINISTRATION OF
PRESCRIPTION MEDICATION IN SCHOOL
A. To be completed by the parent or guardian:

I request that my child _______________Grade:______________DOB ____________ receive the medication as prescribed below by our physician. The medication is to be furnished by me in the properly labeled original container from the pharmacy*. Signature (Parent or Guardian): ________________________________________________
B. To be completed by physician:

I request that my patient, as listed below, receive the following medication: Name of Student DOB ____________________ _ Diagnosis: _________________________________________________________________ MEDICATION
FREQUENCY/TIME
TO BE TAKEN
ADMINISTRATION
Possible Side Effects and Adverse Reactions (if any): _ This patient has a life-threatening condition and should be permitted to self-carry and self-administer their medication. Physician's Signature Date:______________________ Address: Phone:_____________________ * Medication must be in original pharmacy labeled container with specific orders and name of medication. Medication and refills must be brought to school by parent, guardian or responsible adult.
Plan reviewed with parent(s)/guardian(s):
Parent Signature:_________________________________Date:_______________________
Nurse Signature:_________________________________ Date:_______________________
Lunch and Beverage Program Enrollment Form If you wish your child to participate in the school lunch program
ber 9 with a check for either the annual am onth’s cost. There is no need to sign up for beverage service as well since organic m ilk is included in the cost of the lunch program. Full year cost:
Cost for September only:
______________________________________________________________ Please identify any specific food allergies: ___________________________ ______________________________________________________________ Please identify any specific food allergies: ___________________________ ______________________________________________________________ Please identify any specific food allergies: ___________________________ If you choose to send lunch from home, you can still have your child participate in the milk program.
Participating children will receive 2% organic milk each day. (Please note that we are not offering juice as an
option next year — this is a milk only program.) This is only offered as an annual enrollment.

Full year cost: $123 per child (about $0.75 per day)
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Families of children participating in the school lunch program on a daily basis will be billed $8.50 per lunch at the end of each month. How do we track participation? If your child participates in the lunch program on any given day, he or she
simply places a finger on a scanner and the system automatically records the date and time indicating their
participation, all in less than one second. This requires that the school maintain an electronic image of each
child’s fingerprint. The image is housed in a secured database apart from the student’s personal identification
and is only associated with a randomly assigned numeric id. This information is not used for any other
programs in the school. Please don’t hesitate to call if you have any questions or if you don’t want your
child(ren)’s participation in lunch tracked in this manner.

Source: http://www.stlukeschool.org/uploaded/redesign_2013/Programs_2013/Mandatory_Forms_Booklet_2013-2014_Final.pdf