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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