Download Request to Administer “Occasional-use” Medication

Request to Administer “Occasional-use” Medication
A release must be signed each year by a parent/legal guardian and kept on file in the health room for a student to receive medications at school, if such a
need arises during a school day. Please indicate on the list below which medications the student may be given occasionally at school and the amount.
Please do not put daily or prescription medications, such as an Inhaler or Ritalin, on the list. A separate request form for prescription
medication administration must be signed by the physician and parent for the student to receive any prescription medications at school.
Acetaminophen
Amount ____________
Ibuprofen
Amount ____________
Cough/sore throat drops
Antacid tablet
Zyrtec or Benadryl; for allergic reactions
Amount ____________
Drowsiness
YES
NO
Creams/Ointments (Neosporin, A&D Ointment, Icy Hot, Anti-Itch/Hydrocortisone Cream)
No medication to be dispensed to my child unless in an emergency situation that has been evaluated by school personnel or
emergency services.
Allergies to medication
yes
no. If yes, please list medications and reaction.
__________________________________________________________________________________________________________________
List other allergies and reactions:
__________________________________________________________________________________________________________________
Please check health concerns your child currently has:
vision problems
hearing problems
speech problems
diabetes
seizures
asthma
headaches
stomach upset
fainting spells
heart problems
frequent ear infections
attention deficit
nosebleeds
skin rashes or hives
other _____________
Please explain if any of the health concerns may require special attention at school: _______________________________________________
List medications currently taking: ______________________________________________________________________________
__________________________________________________________________________________________________________________
PLEASE INITIAL EACH AND SIGN BELOW:
___ I understand that any school employee who administers the medication to my child in accordance with the written instructions shall
not be liable for damages as a result of an adverse drug reaction or because of a mislabeled or altered product
____ I hereby authorize the physician in charge of (student name) ___________________________________________ to administer any
treatment or to administer such anesthetics, perform such operations as may be deemed necessary or advisable in the diagnosis and
treatment of this patient. I accept the treatment deemed necessary by the physician treating the emergency. If time allows I prefer that the
above named physician treat my child. I hereby give my permission for my child’s medical information to be shared with other Topeka
Collegiate School personnel.
____ I agree to hold Topeka Collegiate School harmless for any injury incurred by my child as a result of typical play and participation in school
activities. I agree to pay all costs and fees incurred for medical treatment.
____ I hereby authorize Topeka Collegiate School to release immunization and relevant medical information in their possession relating to the
said child under the Kansas Immunization Registry (Immunization information disclosed to the registry will be used for purposes of
assessment and reporting to prevent disease.) I understand that this authorization will expire when my child is no longer enrolled at Topeka
Collegiate School and that I may revoke this authorization in writing at any time.
Parent/Guardian Signature: _______________________________________________
Date: __________________________________
Witness Signature: ______________________________________________________
Date: __________________________________
Page 2 of 2 (please return both pages to the school)
Topeka Collegiate School Health Form 2016-2017
Student Name ____________________________________________________ Birth Date ________________ Grade _________
Home Address __________________________________________________________ Home Phone _______________________
Guardian 1 Name __________________________________________________
Cell Phone __________________________________
Company/Place of Employment ___________________________________ Work Phone _________________________________
Email Address _______________________________________________
Guardian 2 Name __________________________________________________
Cell Phone __________________________________
Company/Place of Employment ___________________________________ Work Phone _________________________________
Email Address _______________________________________________
Guardian 3 Name __________________________________________________
Cell Phone __________________________________
Company/Place of Employment ___________________________________ Work Phone _________________________________
Email Address _______________________________________________
Guardian 4 Name __________________________________________________
Cell Phone __________________________________
Company/Place of Employment ___________________________________ Work Phone _________________________________
Email Address _______________________________________________
IN CASE OF EMERGENCY
In the event that a parent/guardian cannot be reached, please list someone in the area who may be contacted in the event of illness or injury:
Name ____________________________________________ Home Phone ___________________ Cell Phone ______________________
Relationship ________________________________________
Work Phone ___________________
Student’s Physician ___________________________________________________________
Office Phone ________________________
Hospital Preference? _____________________________________________________
Authorization to Pick-Up Student:
Please list below all persons, besides parents/guardians, who are authorized to pick up your child from school. NOTE: For your child’s safety all
authorized persons, who are not known by the staff member, will be asked to show photo identification. Please inform the persons on this list in
advance about this precautionary measure. Persons may be added to this list or removed at any time. This is the parents’ responsibility to inform
the office of any changes to this form. Your child WILL NOT be released to anyone who is not authorized.
Name
Relationship to Child
Page 1 of 2 (please return both pages to the school)
Phone Number