Student Health Permission Form

STUDENT HEALTH PERMISSION FORM

Student Information

Date of Birth:    Student ID:    Grade/Program:

Parent / Guardian Information (if student is minor)

Relationship:    Primary Phone:

Emergency Contact

Relationship:    Phone:

Health Insurance / Physician

Policy / ID Number:    Physician Name:    Physician Phone:

Medical History & Current Conditions

Medications

Will the student require medication during school hours?   Yes

For any prescribed medication administered at school, a physician's written order and the original pharmacy-labeled container are required.

Administration details (for a specific medication):  Name:   Dosage:   Schedule:

Route:   Start Date:   End Date:

Permissions & Authorizations

By checking the boxes below and signing this form, I give the school and its authorized health personnel the following permissions within the limits described:

Permit administration of routine over-the-counter medications (e.g., acetaminophen, ibuprofen, antihistamines) per school dosing policy and with prior written parental directions.

Permit administration of prescribed medication at school when accompanied by a physician's order and pharmacy-labeled container.

Permit trained school personnel to administer epinephrine (auto-injector) in the event of anaphylaxis and to call emergency services if indicated.

Permit student to self-carry and self-administer an inhaler or epinephrine auto-injector when physician authorization and parental authorization are provided.

Permit school personnel to arrange or consent to emergency medical treatment and transportation (ambulance/EMS) if I cannot be reached. I understand that every effort will be made to contact the parent/guardian or emergency contact.

Permit the disclosure of relevant health information to emergency responders, medical personnel, and school staff on a need-to-know basis to ensure proper care.

Immunization & Tetanus

I certify that the student's immunizations are current to my knowledge and documentation has been provided to the school.

Last tetanus shot (if known):

Legal Authorization, Acknowledgments and Release

I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize school nurses, designated school staff, and emergency medical personnel to provide, administer, or obtain routine and emergency medical treatment reasonably necessary to protect the health and safety of the student while under the school's supervision. Such treatment may include, but is not limited to, first aid, emergency stabilization, administration of epinephrine, oxygen, medication as authorized herein, and transportation to an appropriate medical facility.

I understand that the school will attempt to contact me and/or the emergency contact prior to or promptly following any emergency care. I understand that if I refuse to authorize emergency medical treatment, the school may still seek such treatment in circumstances where delay would endanger the student.

By signing below I release and hold harmless the school district, its employees, agents, and volunteers from any liability for ordinary negligence arising from the administration of medications or emergency care authorized by this form, except for acts of gross negligence or willful misconduct.

This authorization is effective from the date signed below and remains in effect until the end date indicated below or until revoked in writing by the undersigned.

Effective From:    To:    (Leave blank if authorization is indefinite until revoked.)

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