PR ENTICE SUMMER MEDICAL FOR M INFOR MATION
The attached medical forms include:
1.
“Emergency/Medical
Information Form”
REQUIRED FOR ALL STUDENTS
2.
“Medical Treatment Consent
Form”
REQUIRED FOR ALL STUDENTS
3.
“Parent/Guardian & licensed
authorized health care
provider/dentist Request for
Prescribed Medication”
REQUIRED for ANY student who takes PRESCRIPTION MEDICATION that needs
to be administered by school staff for ANY REASON including:
1. During school hours
2. On an “as-needed” or emergency basis (including inhalers & EpiPens)
Please complete the required forms and obtain the appropriate signatures (if applicable) and return to The
Prentice School within 3 days of enrolling via fax (714-538-5004), email [email protected], mail, or drop-off
at front desk.
Regarding Medications:
Medical treatment is the responsibility of the parent/guardian and an authorized health care provider. An authorized health care
provider is an individual who is licensed by the State of California to prescribe medication. Both prescription and over the
counter medication may be given at school when it is deemed absolutely necessary by the authorized health care provider
that the medications be given during school hours. California Education Code, Section 49423 allows school personnel to assist
in carrying out an authorized health care provider’s written orders. The parent/guardian is urged, with the help of your
child’s authorized health care provider, to work out a schedule of giving medication at home whenever possible.
Emergency medicine such as EpiPens or inhalers may be carried by the student (GRADES 5 – 8 ONLY) when
recommended by an authorized health care provider and parent. Back-up medication should be kept at school for
emergency use. Students who have a serious medical condition (diabetes, epilepsy, etc.) should have an emergency supply of
their prescription medication at school with the appropriate consent forms in the event of a disaster.
If medication is to be administered at school, all of the following conditions must be met:
1. Parent/guardian and an authorized health care provider must complete and sign the required form
and return to the Prentice School.
2. Medication must be delivered and refilled to the school by the parent/guardian or other responsible
adult. Over-the-counter (OTC) medication must be in the original, unopened, container.
3. Medication must be in your child’s original, labeled pharmacy container written in English. The
parent/guardian should write the student’s first and last name on the OTC medication.
4. All liquid medication must be accompanied by an appropriate measuring device.
5. Any tablets requiring partial doses (½ or ¼) must be sent to school already cut.
6. A separate form is required for each medication.
Whenever there is a change in medication, dose, time, or route, the parent/guardian and authorized health care
provider must complete a new form.
EMERGENCY/MEDICAL INFORMATION FORM
Summer 2017
This is a m andatory form that m ust be completed for each student for each new school year.
Complete All Sections
Please PRINT
STUDENT INFORMATION
First Name:
Last Name:
Grade (SY 2016-17):
Street Address:
DOB:
City:
State:
Zip:
Home Phone:
MOTHER/GUARDIAN INFORMATION
FATHER/GUARDIAN INFORMATION:
Name:
Name:
Cell:
Cell:
Employer:
Employer:
Home Address, City, State, Zip:
Home Address, City, State, Zip:
(If different from above)
(If different from above)
Work Phone:
Work Phone:
Email:
Email:
MEDICAL INFORMATION
Please provide a brief medical history for Prentice to keep on file in the event of emergency medical treatment by medical professionals.
Does student have any unusual health conditions? (If YES, please check below) ___Yes ___No
Student's Blood Type:
__ Asthma
__ Kidney/Bladder
__ Arthritis
__ Wears Glasses/Contacts
__ Headache/Migraine
__ Convulsive Seizures
__ Internal Irregularities
__ Diabetes - Mild
__ Diabetes - Severe
__ Wears Hearing Aid
__ Physical Handicap (Describe)
Does student have any allergies?
__ Other (Describe)
__ Yes
__ No
__
__ Medication Allergy
Bee Sting Allergy
___ Peanut Allergy
__ Other: (Describe)
STUDENT RELEASE INFORMATION
I authorize the following people to pick up my child from school:
Please list in order of priority
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
I HEREBY AUTHORIZE PRENTICE STAFF TO RELEASE MY STUDENT TO THE ABOVE LISTED PERSON(S)
PARENT/GUARDIAN SIGNATURE:
NOTE: If there is any legal reason for which an individual is Not allowed to pick up or interact with your child, please write the names(s)
below and provide The Prentice School with a copy of legal documentation so that we may place it in your child's file
Name:
Relationship:
MEDICAL TREATMENT CONSENT FORM
Summer 2017
This is a m andatory form that m ust be completed for each student for each new school year.
Student First Name:
Student Last Name:
DOB:
Name of Medical Insurance Provider:
□ I AUTHORIZE
□ I DO NOT AUTHORIZE
Age:
Policy/Contract/Group #:
The Health Clerk or other designated staff to give my child the common medications (or
generics) listed below, if needed, at school.
----- I HAVE CROSSED OUT THE M EDICATION S THAT I DO NOT W ISH M Y CHILD TO R ECEIVE. ----ANALGESICS
HEARTBURN & INDIGESTION
THROAT
Sting/Bite Relief
Ibuprofen
Calcium Carbonate
Throat Lozenges (5 and over)
Calamine Lotion
Acetaminophen
LIPS
TOPICALS
EYE
ALLERGY
Petroleum Jelly
Antibiotic Ointment
Eyewash
Antihistamine
MOUTH
Antiseptic Towelette
Eyedrops/Artificial Tears
COLD
Oral Pain Reliever (12 and over)
Alcohol Towelette
Contact Lens Solution**
Dextromethorphan
Dental Wax
Antiseptic Pain Reliever with Aloe
**Students with contacts should bring both
CONSTIPATION
NAUSEA
Hydrocortisone Cream
Milk of Magnesia
Bismuth Subsalicylate (12 and over)
Hydrogen Peroxide
re-wetting and cleaning solutions along with
an extra case and/or extra pair of lens (if
disposable)
If you do not give consent, please provide instructions:
□ YES
□ NO
my child requires prescription medication (including rescue inhaler or EpiPen) that needs to be taken
during school hours AND/OR on an emergency or “as-needed” basis.
If you answ ered “YES”, you M UST com plete an ADDITION AL form, “P arent/ Guardian & Physician Request for M edication”, w hich
requires BOTH a parent/ guardian AN D a licensed authorized health care provider/ dentist to fill out and sign.
N O PR ESCR IPTION M EDICATION S W ILL BE GIVEN W ITHOUT THIS FORM
RELEASE OF LIABILITY, AGREEMENT TO HOLD HARMLESS, AND COVENANT NOT TO SUE: To the full extent permitted by law, I/we knowingly and voluntarily release and
covenant not to sue The Prentice School, its trustees, officers, directors, employees, agents, representatives, coaches, volunteers (the Released Parties) from any and all claims and
liabilities that arise out of, or relate to The Prentice School’s administration of medications (prescription or non-prescription) to my child consistent with the terms of this form, or my
child’s self-administration of medications while on campus or at a School-related event, or the rendition of any medical treatment to my child that has been authorized by The Prentice
School acting pursuant to this form. I understand however, that through this Agreement I am not releasing the Release Parties from any injury my child suffers as a direct result of the
Released Parties’ intentional misconduct or gross negligence. I further agree to hold The Prentice School harmless and to defend The Prentice School for all costs, expenses, judgments
or any other liability to any other person who shall assert any claim on behalf of themselves or my child that arises out of, or relates to, the Prentice School’s administration of medications
to my child consistent with the terms of this form, or my child’s self-administration of medication while on campus or at a School-related event, or the rendition of any medical treatment
to my child that has been authorized by The Prentice School acting pursuant to this form. By my signature below, I acknowledge that I have fully read and understand that I am releasing
and covenanting not to sue The Prentice School on behalf of my child, myself or any other person and holding it harmless, according to the terms of this paragraph.
CONSENT FOR MEDICAL TREATMENT & RELEASE FROM LIABILITY: In the event my child becomes ill or injured and, in the sole and unfettered discretion of any one of the
Released Parties, requires immediate medical or dental care or attention at any School or School-related practice, game, program, trip, or similar event (on or off campus) or while
otherwise on school premises, I authorize the School and their agents or employees to consent on my behalf to x-rays, examinations, anesthetic, medical or surgical procedure, treatment
or hospital care, which are deemed advisable by and to be rendered under the supervision of any physician, surgeon, or dental surgeon licensed under the provisions of California state
law, whether such diagnosis or treatment is rendered at the scene of the event, the office of a physician or dentist, or at any hospital. I understand and agree that this consent to
treatment in advance following the provisions of California Family Code §6910 does not relieve the parent or guardian for all financial responsibilities for such treatment. I understand
that The Prentice School will make a reasonable effort to contact me to assist in any decision made by the school, but that the School will be compelled to use its best judgment should
it not be possible to contact me. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide
authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist
in the exercise of his best judgment may deem advisable.
ASSUMPTION OF RISK: I assume all risks arising out of, or relating to The Prentice School or any of the Released Parties providing prescription and/or non-prescription medication to
my child consistent with the terms of this form/physician’s instructions. I have fully investigated the procedures by which The Prentice School and each of the Released Parties administers
and supervises self-administration by students of medication, and I expressly agree that I am satisfied with them with regard to my child. I acknowledge that the risks to my child
include, but are not limited to, failure of any such medication (so long as it has been authorized for sale and/or distribution in California by state or federal authorities) to be safe and/or
effective, mild or severe adverse physical reaction to the prescription and/or non-prescription medication provided (including emotional/psychological harm), permanent and temporary
disability, and death. I agree that my child will also assume these risks and any other risks arising out of, or relating to, The Prentice School or any of the Released Parties providing
prescription and/or non-prescription medication to my child consistent with the terms of this form.
USE OF HEALTH RECORD: All of the information I provided during online registration relating to the medical history and information regarding my child is complete, true, and correct.
I hereby give permission for this information to become part of the student’s educational record and give permission to The Prentice School to share the student’s medical information
with school personnel who have legitimate educational interests in this information and to provide any such information to any medical personnel in connection with any medical treatment
provided to my child.
I HAVE CAREFULLY REVIEWED THIS FORM AND FULLY UNDERSTAND ITS CONTENTS (INCLUDING THAT THIS FORM CONTAINS CERTAIN RELEASES OF LIABILITY
AND OTHER PROVISIONS AFFECTING MY CHILD’S AND MY LEGAL RIGHTS AND DUTIES), AND AGREE THERETO. THIS AUTHORIZATION SHALL REMAIN EFFECTIVE
FOR THE FULL SCHOOL YEAR UNLESS REVOKED IN WRITING AND DELIVERED TO THE PRENTICE SCHOOL AND A RECEIPT FOR THE REVOCATION IS ISSUED.
PARENT/GUARDIAN SIGNATURE
DATE
PARENT/GUARDIAN PRINTED NAME
PARENT/GUARDIAN & LICENSED AUTHORIZED HEALTH CARE
PROVIDER/DENTIST REQUEST FOR PRESCRIBED MEDICATION
Summer 2017
Student First Name:
Student Last Name:
DOB:
Grade:
PARENT/GUARDIAN REQUEST FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION
California Education Code Section 49423 provides that pupils who are required to take prescribed medications during the school day can be and will
be assisted by the Health Clerk and/or other designated School Personnel ONLY if the school receives the written request from said licensed
authorized health care provider/dentist and the parent/guardian(s) of named student. All prescription medication to be administered at school must
be in the original pharmacy container labeled with the following information: Student name, Name of medication, Dosage and strength of medication,
Time and frequency of administration, Route of administration, Physician’s/Prescriber’s name, Date of order, Expiration date of medication is earlier or
as printed on the pharmacy label.
I request that medication be administered to my child in accordance with our licensed authorized health care provider/dentist written instructions. I
understand that designated school personnel will administer the medication. I will notify the school immediately and submit a new form if there are
changes in medication, dosage, time of administration. I will replenish medication supply as needed. I will give first dose of any medication at home
and observe for adverse reactions.
PARENT/GUARDIAN SIGNATURE:
DATE:
Emergency medicine such as an EpiPen or inhaler may be carried by 5-8 grade students ONLY when recommended and signed by a
licensed authorized health care provider/dentist and parent. Back up medication should be kept at school for emergency use.
LICENSED AUTHORIZED HEALTH CARE PROVIDER/DENTIST REQUEST FOR THE ADMINISTRATION OF
PRESCRIPTION MEDICATION
**** P rescribing physician must com plete this section. ****
Reason for medication (diagnosis):
Medication:
Dose:
If PRN: Amount of time between doses:
Route:
Time:
Maximum number of doses per school day:
Possible medication reactions:
Instructions for emergency care:
Date of request:
Date to discontinue medication:
When was first dose of this medication given?
The above medication can’t be scheduled for other than school hours and may be
administered by school personnel.
Physician’s Printed Name:
Date:
Address:
Phone:
Fax:
PHYSICIAN’S SIGNATURE:
*****GRADES 5 – 8 ONLY*****
Regarding EpiPens/Inhalers: It is my professional opinion that this student should be permitted
to carry/self-administer this emergency EpiPen or inhaler. This student has been instructed in, and
demonstrates an understanding of proper usage.
Health Care Provider Initials:
THIS R EQUEST IS VALID FOR THE CUR R EN T SCHOOL YEAR .
OFFICE USE ONLY:
A SEPARATE FORM IS REQUIRED FOR EACH MEDICATION
Health Office Staff:
Medication Name Rec’d:
Date Form Rec’d:
Amt:
Date Meds Rec’d:
Office Stamp