Dear Parent(S) Or Legal Guardian(S)

May 23, 2013

Dear Parent(s) or Legal Guardian(s):

As a residential school based health center, we are required to have written physician’s orders to authorize the dispensing and use of all medications and to provide prescribed treatments to any student. All orders must have a Dr.’s signature on the form. This includes regular prescriptions, as needed (prn) prescriptions, over the counter and first aid medications. You are responsible for obtaining initial orders before the beginning of the schoolyear. Please have your physician mail or fax (502-897-1282 Health Center secure fax line) orders to cover all of your child’s medication and treatments for the coming year by July 1, 2013. Failure to have these signed orders may result in your child returning home. All medication must be in the original prescription bottle with pharmacy label intact.This will help speed up our registration process, because we will already have their medication administration record and medicine cards filled out and ready to go.

The KSB health center has a physician that provides us with standing orders to treat children when they are ill. In the event of serious illness or injury your child will be transported to a local hospital. We will attempt to notify you before we transport.

The KSB Health Center does not administer immunizations. We monitor your child’s immunization record for compliance with the Kentucky Department of Health. We will notify you when immunizations are needed. It is your responsibility to have your child immunized.

Please provide the health center with copies of all insurance cards or medical cards. Be advised if you do not notify us of changes in coverage/provider you may be billed directly for services provided for your child.

At times it may be necessary to share information with other staff members that care for your child.

I have read and understand the above information and will comply with its directives.

Student Name______

Parent/Guardian Signature ______Date______

Parent/Guardian Signature ______Date______

TWO SIDED FORM PLEASE READ AND SIGN BOTH SIDES

Consent for HealthCenter Services

2013-2014

As the parent(s), legal guardian of ______. We (I) consent to Health Center services provided by the Kentucky School for the Blind Health Center staff of nurses, physician, and individual appropriately trained assistive personnel. These services may include assessment, treatment, medication administration, and injections following physician standing orders. If an emergency, will transport student to Emergency Room by Health Center assistive personnel or EMS will transport if necessary.

Mother’s Signature ______

Father’s Signature ______

Guardian’s Signature ______

Relation to Student ______

.

• Please send a copy of Legal Guardianship Papers

Updated 5/23/13

TWO-SIDED FORM PLEASE READ AND SIGN BOTH SIDES