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STATEMENT OF CONSENT - I authorize school personnel to obtain emergency medical care for my student in the event I cannot be reached. If transportation by ambulance is required, this may be obtained. In addition, all the information provided below is accurate to the best of my knowledge and may be shared on a need to know basis with select personnel when my child’s health and well being require knowledge of a health concern.

MUST BE SELECTED TO TREAT FOR AN EMERGENCY!!

I Consent Please select this field.

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Parent Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Preferred Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number 1 REQUIRED Please fill out this field. Please enter a phone number.

Alternate Phone Number 2 Please enter a phone number.

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Student Information

Student Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Grade of Student REQUIRED Please fill out this field.

Health Insurance? REQUIRED

Is this student covered by Health Insurance?

Yes No Please fill out this field.

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Physician Name REQUIRED Please fill out this field. Please enter valid data.

Physician Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Hospital Preference REQUIRED Please fill out this field. Please enter valid data.

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Dentist Name Please enter valid data.

Dentist Phone Number Please enter a phone number.

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Orthodontist Name Please enter valid data.

Orthodontist Phone Number Please enter a phone number.

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* Asthma and Allergies - Describe all foods, medications and / or environmental causes that may trigger asthma or allergy symptons.

Food Allergies

Food Allergies - history of hives, wheezing, facial swelling or tests positive for food allergy. Please document.

Insect Sting Allergies

Please indicate insect allergies.

Medication - Chemical - Food Additive - Allergies

Allergy to medication(s), latex, chemicals or food additives. Please document.

Asthma / Allergy Triggers

Cold air, viral cold symptoms, animal danger, dust mites, etc.

Seasonal Allergies Fall Winter Spring

List Treatment for Seasonal Allergies

PRESCRIPTION MEDICATION - Child Takes at Home

Please include medication, dosage, frequency

Special Concerns - Recent Surgeries

Please list any special concerns that pertain to your child's health or recent surgeries!

OVER THE COUNTER MEDICATION

If you want the school nurse to dispense Over The Counter Medication for your child while they're at school please complete the following.

Notify Parent Before Dispensing Medication? Yes No

Over the Counter Medication

Check all that apply!

Neosporin / Polysporin Hydrocortisone / Benadryl Cream Benadryl (Oral) Acetaminophen (ex. Tylenol) Ibuprofen (ex. Advil / Motrin) Tum Tablets Cough Drops

All Over The Counter Medication will be dosed by child's weight, or recommendation on the bottle unless otherwise specified by physician.

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PRESCRIPTION MEDICATION TO BE GIVEN AT SCHOOL

If you want the school nurse to dispense Perscription Medication for your child while they're at school please complete the following.

All PERSCRIPTION MEDICATION that needs to be given while at school MUST be in the pharmacy bottle labeled with the name of the child, medication, dosage, and physician's name; the label will serve as the physician's signature. The school must be notified in writing if medication is discontinued.

Number of Medication(s) REQUIRED Please fill out this field.
Number of Medication(s) 1
- Medication
  Example - Albuterol
  Please enter valid data.
- Dose to be Given
  Number of Puffs or Dosage Amount
  Please enter valid data.
- Time of Day to be Given Please enter valid data.
- Reason for Medication Please enter valid data.
- Possible Side Effects Please enter valid data.
Number of Medication(s) 3
- Medication
  Example - Albuterol
  Please enter valid data.
- Dose to be Given
  Number of Puffs or Dosage Amount
  Please enter valid data.
- Time of Day to be Given Please enter valid data.
- Reason for Medication Please enter valid data.
- Possible Side Effects Please enter valid data.
Number of Medication(s) 4
- Medication
  Example - Albuterol
  Please enter valid data.
- Dose to be Given
  Number of Puffs or Dosage Amount
  Please enter valid data.
- Time of Day to be Given Please enter valid data.
- Reason for Medication Please enter valid data.
- Possible Side Effects Please enter valid data.
Number of Medication(s) 5
- Medication
  Example - Albuterol
  Please enter valid data.
- Dose to be Given
  Number of Puffs or Dosage Amount
  Please enter valid data.
- Time of Day to be Given Please enter valid data.
- Reason for Medication Please enter valid data.
- Possible Side Effects Please enter valid data.
Number of Medication(s) 2
- Medication
  Example - Albuterol
  Please enter valid data.
- Dose to be Given
  Number of Puffs or Dosage Amount
  Please enter valid data.
- Time of Day to be Given Please enter valid data.
- Reason for Medication Please enter valid data.
- Possible Side Effects Please enter valid data.

It's critical to review this information before clicking the submit button!

Queen of the Holy Rosary - Wea School

22705 Metcalf RD
Bucyrus, KS 66013
913.533.2462

School Health Form

School Health Form

[email protected] or call at (913) 879-1024

Parent Information

Student Information

OVER THE COUNTER MEDICATION

PRESCRIPTION MEDICATION TO BE GIVEN AT SCHOOL

It's critical to review this information before clicking the submit button!