Microsoft word - emergmed.doc

Emergency Care and Medication Form 2007-2008
Grace Church SchoolAttention: School Nurse86 Fourth AvenueNew York, NY 10003 To be completed by Parent or Guardian:
Child’s Name_____________________________Grade__________Date of Birth____________ Cell#______________________________________________ Person to contact if unable to reach parents: I give my permission for the school’s nurse or designated employee to administer first aid if such is needed.
In the event that I cannot be reached and emergency hospital care/treatment is needed, I give my permissionfor my child to be taken to the nearest hospital and given the necessary emergency care.
Signature of Parent/Guardian: ________________________________Date__________________ Insurance Provider______________________________________________________________ Medication Permission
*Signature of Physician and Parent/Guardian required for all medications. Please indicate below which
medications may be administered by the School Nurse or designated employee.
Acetaminophen (Tylenol) 240/650mg PRN for pain_________ Benadryl 12.5/25 mg. PRN/Allergic reactions_____Ibuprofen( Motrin) 200/400 mg PRN for pain_______ Other Medications________________________________________________________________ Allergies_______________________________________________________________________
Allergy Medication and Protocol_____________________________________________________ _______________________________________________________________________________ EPI PEN will be kept at school or on student____________________________________________
*Medication as indicated by parents may be administered*I have examined this student and have found his/her physical exam within normal limits.
He/she is physically fit to participate in Physical Education and/or sports.
PHYSICIAN SIGNATURE_____________________________________ PARENT’S SIGNATURE________________________________________________________ PHYSICAL EXAMINATION FOR 2007-2008 SCHOOL YEAR
O.S.________: Hearing:Rt_______Left___________ Family History_________________________________________________________________ _____________________________________________________________________________ Significant Past Illness, Injuries, Operations__________________________________________ _____________________________________________________________________________ Nutritional Evaluation____________________________________________________________ Developmental Assessment________________________________________________________ Current Medical Problems_________________________________________________________ Allergies (food, drug, environmental)________________________________________________ Immunizations during Past Year____________________________________________________ (Required for new students in Jr.K.through Gr.8) (Required for new students in Jr.K and K; (If limited, please explain___________________ _________________________________________________________________________________ Signature of Examining Physician____________________________________

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