The Following Are Attached

The Following are Attached:

Health History(MUST COMPLETE AND RETURN)

Medication Authorization Permit

Prescription Meds

ONLY RETURN IF CHILD IS ONA PRESCRIPTION MEDICATION FROM THE DOCTOR

Non-Prescription Meds

RETURN WITH MEDICATION

IMPORTANT MESSAGE FOR PARENTS FROM THE SCHOOL NURSE

Welcome to a new school year! The attached packet contains important information regarding your child’s health that will help ensure the safety of your child throughout the school year.

Prescribed medications will not be given at school, unless we have the completed form. This means every time your child is sick and requires prescription medication, you MUSTsend the attached “Medication Authorization Permit” after your health care provider has completed the required information. Extra consent forms are available in every school’s front office.

All medication must be brought to school in the original container. Students are not allowed to carry any medication with them while at school. All medicationsmust be brought to the school nurse or front office for storage. The only exception is an Epi-Pen or inhaler, which may be kept with the student after the “Medication Authorization Permit” has been completed by healthcare provider.

If you wish for your child to receive any over-the-counter medication, (such as Tylenol, Tums, Ibuprofen, or cold medication), you MUST send the medication in the original container with a signed “Medication Authorization Permit”.

Please return the completed consent forms to school as soon as possible to help this process run smoothly. REMEMBER: Your child cannot be given or carry medication without the proper forms filled out and returned.

With your help, we hope to make this year a great one!

Thank you,

Elisha Childress, RN

Cristy Evans, RN

Prescription Medication

(Completed by Healthcare Provider)

Students Name: ______School: ______

Diagnosis/Reason for Medication ______

For Food Allergies: (please circle one or both) Air Borne Ingestion

Food Substitutions: ______

Medication Dose Route ______

Frequency ______Duration (not to exceed current school year)

Times to be given Start Date: Stop Date: ______

Special Instructions for Administration

Potential Adverse Reactions

Phone Number: ______

(Healthcare Provider’s Signature)

Address: ______Date: ______

The undersigned parent/guardian for himself/herself and the minor child hereby releases and discharges the Dyer County School System, its agents, employees and officers, including but not limited to the individual member of the Board of Education, the Superintendent and his staff, and all principals, teachers and teacher’s aides from all claims, demands, actions, judgments and executions which the undersigned ever had, or now has, or may have against the Dyer County School System its successors and assigns for any and all injuries, known or unknown, and of any type, caused by or arising out of, the above described administration of medication or performance of medical procedures prescribed and set forth above. The undersigned agree to indemnify, defend and hold harmless the parties released herein from any claim arising from or related to the claims herein released, if said claims are hereafter asserted or attempted to be asserted.

I hereby give permission for personnel designated by the principal or school nurse to give the above medication to my child according to the directions stated. I acknowledge my child is competent to self administer the above medication.

I/we the undersigned have read this release and understand all of its terms. I/we execute it voluntarily and with full knowledge of its significance.

____ Date: ______

(Parent or Guardian Signature)

Non-Prescription Medication

(Completed by Parent/Guardian)

MUST PROVIDE MEDICATION WITH THIS FORM

Student Birth date

School Grade Teacher/HR______

Over the Counter Medication: ______

(Tylenol, Tums, Ibuprofen, cold medicine, Benadryl, Midol, etc.)

Dose: ______(not to exceed manufacturer’s maximum dose)

Route/Mode of Administration: (Mouth, Skin, Eye Drops, etc.)

Frequency: ______

State conditions under which school personnel should allow student to self-administer medication

provided by parent/guardian: (Headache, Fever, Pain, Indigestion, Cough, etc)

______

The undersigned parent/guardian for himself/herself and the minor child hereby releases and discharges the Dyer County School System, its agents, employees and officers, including but not limited to the individual member of the Board of Education, the Superintendent and his staff, and all principals, teachers and teacher’s aides from all claims, demands, actions, judgments and executions which the undersigned ever had, or now has, or may have against the Dyer County School System its successors and assigns for any and all injuries, known or unknown, and of any type, caused by or arising out of, the above described administration of medication or performance of medical procedures prescribed and set forth above. The undersigned agree to indemnify, defend and hold harmless the parties released herein from any claim arising from or related to the claims herein released, if said claims are hereafter asserted or attempted to be asserted.

I hereby give permission for personnel designated by the principal or school nurse to give the above medication to my child according to the directions stated. I acknowledge my child is competent to self administer the above medication.

I/we the undersigned have read this release and understand all of its terms. I/we execute it voluntarily and with full knowledge of its significance.

Date ______

(Parent or Guardian Signature)

Cell Phone______Work Phone______Home Phone______