Student Health Information (please print)

Student’s Name: ______ID#______

Birthdate: ______M___ F___

Grade: ______Teacher: ______

Does your child have ANY history of … (check all that apply):

___ Allergies ___ Asthma

___ Food Allergies ___ Seizures

___ Diabetes ___ Cancer

___ Sickle Cell Disease ___ Physical Impairment

Give details: ______

______

______

Does your child … (check all that apply):

___ Use an inhaler Frequency ______

___ Use an EpiPen

___ Take prescribed medication(s) routinely

___ Require special seating in the classroom

___ Have any condition that limits participation in P.E.

Give details: ______

______

Did your child receive any immunizations this past year?

Y N Type/Date: ______

Date of last tetanus shot: ______

Medication Authorization (please print) Name only the medication you are sending on this trip. You will need to complete this form for each medication being sent.

Student’s name: ______

Condition requiring medicine: ______

______

Name of medicine: ______

Storage requirements: ___ None ___ Refrigerate

Dosage: ______

Instructions: ______

______

Possible side effects: ______

Physician: ______

Physician phone: ______

Parent/Guardian: ______

Parent/Guardian phone: ______

I authorize the principal or his/her designee to give medicine to my child according to the stated directions.

______

Parent/Guardian Signature Date

I authorize the principal or his/her designee to contact my child’s physician if additional information regarding medication is needed.

______

Parent/Guardian Signature Date

The principal or his/her designee will dispense medicine to students according to the following guidelines:

Medicine cannot be given without written permission and instructions from the parent/guardian. A new Medication Authorization must be completed whenever a new medicine or dosage is to be given to the student.

The parent/guardian must bring medicine and related equipment to the designated teacher. Students must not be in possession of medicine. All medication must be kept in the possession of said designee.

Prescription medicine must be in the original labeled container. Over-the-counter medicine must be in the original container and marked with the student’s name.

If students are injured or become ill while on the trip, the designee

will attempt to notify parents/guardians and act according to the parent’s/guardian’s

directions. If parents/guardians cannot be reached, the designee will take the actions

necessary to protect the health and well-being of students.

Henry County School Systems 2011-2012

Field trip Medication dispensed form

Student Name:______ID #:______Grade:______

Teacher:______Field trip to:______Dates:______

AUGUST SEPTEMBER OCTOBER
M T W Th F M T W Th F M T W Th F
1st / 1st / 1st
2nd / 2nd / 2nd
3rd / 3rd / 3rd
4th / 4th / 4th
5th / 5th / 5th

Medication :______dosage:______time to be given:______

Person responsible for giving the medication:______Int:______

NOVEMBER DECEMBER JANUARY
M T W Th F M T W Th F M T W Th F
1st / 1st / 1st
2nd / 2nd / 2nd
3rd / 3rd / 3rd
4th / 4th / 4th
5th / 5th / 5th

Medication :______dosage:______time to be given:______

Person responsible for giving the medication:______Int:______

FEBRUARY MARCH APRIL
M T W Th F M T W Th F M T W Th F
1st / 1st / 1st
2nd / 2nd / 2nd
3rd / 3rd / 3rd
4th / 4th / 4th
5th / 5th / 5th

Medication :______dosage:______time to be given:______

Person responsible for giving the medication:______Int:______

MAY JUNE JULY
M T W Th F M T W Th F M T W Th F
1st / 1st / 1st
2nd / 2nd / 2nd
3rd / 3rd / 3rd
4th / 4th / 4th
5th / 5th / 5th

Medication :______dosage:______time to be given:______

Person responsible for giving the medication:______Int:______

Please note the time the medication is given in the appropriate box. Should the student require medication more than once in a day use the “DAY” column 1st,2nd,3rd etc. per dose.