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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____________________________________

Source: http://000053b.webpreview.dsl.net/pages/parents/documents/JKKEmergMed.pdf

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schützt vor Pilzbefall10 Jahre Langzeitschutz*lösemittelhaltigfür außenfür alle lösemittelhaltigen Lasurenhoch tiefenwirksamfarblosHolzschutzmittel sicher verwenden. Vor Gebrauch stets Kennzeichnung und Produktinformation lesen. n uchsfertiges, flüssiges Holzschutzmittel (PT 8) auf Lösemittelbasis zur Farbloses, gebrauchsfertiges, flüssiges Holzschutzmittel (PT 8) auf Lösemittelba

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Maximum permissible levels (MPLs) of residues of active substances of pesticides in fresh food products of plant origin fixed by Russian legislation in accordance with Hygiene Standard (GN) 1.2.1323-03 MPLs of active substances MPLs in other types of food products in line with the MPL of an active substance file:///C|/Users/Alejandro/Downloads/untitled-2.htm (1 de 29) [28/09/2008

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