West Chicago Community High School Freshman Health

West Chicago Community High School Freshman Health

West Chicago Community High School
Freshman Health Requirements
Dear parents/guardians,
PIease note:
Your child's health forms are due by the 1st day of school. Students will not receive a class schedule and may not
attend school until health requirements are met. Schedules will remain on hold until all documentation is received.
Freshman packets will be mailed out in April, and will contain all required health forms (also available on the school
website). All incoming freshmen must have a complete physical examination within 1 year prior to the first day of
school. Make your appointments early!
If your child arrives at school without the required documentation on the first day of school, parents/guardians will
be called to come and take their child home. Child will remain excluded from school until required documentation is
received by the health office. This is in accordance with IL state law and d94 school policy.
Please contact the health office with any questions or concernsPH: 630-876-6245 (English)
FAX: 630-876-6585
PH: 630-876-6469 (Spanish)
Sincerely,
Annette Snyder, School Nurse.
****************************************************************************************************************************************
Estimados padres / guardines,
Por favor tome nota:
Los requisitos para el comienzo del año escolar de su estudiante serán requeridos el primer día de escuela. Los
estudiantes no tendrán derecho a obtener sus horarios (Schedule) de clases y tampoco pueden asistir a la escuela sin
cumplir con estos requisitos. Los horarios (Schedule) de su estudiante se mantendrám detenidos hasta no recibir
todos los documentos de salud. El paquete de novena grade será enviado por correo en Abril, y contiene todas las
formas médicas, (también están disponibles en el sitio-web) Todos los estudiantes entrando al noveno grado deberán
completar un físico no debe ser más de un año contando el primer día escolar. ¡Agá sus citas pronto!
Si su estudiante llega el primer día escolar sin los documentos necesarios, se les ara una llamada a los padres /
guardianes para que vengan por ellos. No podrán asistir a clases quiere decir que serám excluidos hasta no tener los
documentos necesarios en la oficina de salud, de acuerdo con la pó1iza de las escuelas de IL.
Si usted tiene preguntas, por favor póngase en contacto con la oficina de salud.
PH: 630-876-6469
Sincerely,
Annette Snyder, School Nurse.
WEST CHICAGO COMMUNITY HIGH SCHOOL
326 Joliet Street
West Chicago, IL 60185
630-876-6200 (Phone)
630-876-6585 (Fax)
Dear Parent/Guardian:
Spring 2016 - Welcome!
In just a short while, we will be welcoming your son or daughter to West Chicago Community High School as the class of 2020.
This letter is intended to inform you of the health requirements that are required for your incoming freshmen student.
All forms that are required for enrollment will be on the website as part of the registration packet.
STATE LAW requires all incoming freshmen to present the following documentation in order to enroll:
PHYSICAL EXAM REQUIREMENTS
It is necessary to use the two-sided health examination form issued by the Illinois Department of Public
Health (IDPH), entitled Certificate of Child Health Examination Form. NO OTHER FORM MAY BE USED.
Immunization record with licensed medical provider's signature and date must be provided on the front of the
form.
A current physical examination by a licensed health care provider must be fully completed on the back of the
form (within one year of the first day of school, September 6, 2016).
A parent/guardian must complete the "health history'' portion of the physical form and sign and date in the
indicated space at the top of the back page.
REQUIRED IMMUNIZATIONS
a.
b.
c.
d.
e.
Proof of two measles immunizations, 2 mumps immunizations, and 2 rubella immunizations, the first
dose must have been received on or after the 1st birthday and the second dose no less than 28 days after
the first dose
Proof of a completed series of (3 doses) diphtheria-pertussis-tetanus immunizations; the last
immunization must be a Tdap booster and received after the 4th birthday and at least 6 months after the
previous dose
Proof of a completed series (3 doses) of polio immunizations; the last immunization must be after the 4th
birthday and at least 6 months after the previous dose
Proof of a completed series (3 doses) of hepatitis B immunizations; spacing between the first and second
dose must be 28 days, between the second and third dose must be at least 2 months, and between the first
and third dose must be at least 4 months.
Proof of two varicella immunizations; the first dose must have been received after the 1st birthday and the
second dose no less than 4 weeks later
MAKE YOUR APPOINTMENTS FOR THE PHYSICAL EXAMINATION NOW.
NOTE:
Incomplete and unsigned forms will delay enrollment.
If your son or daughter plans to compete in interscholastic activities next year, the completion of the physical exam on the mandated form
will satisfy the state eligibility requirement. However, to insure that the physical is valid through the spring sport season, we suggest that the
examination be completed after June 1, 2016. By law, we are not permitted to accept a sport physical form In lieu of the IDPH's
required form. The Certificate of Child Health Examination form must still be used.
YOU MUST TAKE AN UPDATED RECORD OF YOUR CHILD'S IMMUNIZATIONS TO YOUR PHYSICIAN APPOINTMENT. To help
assure that you have an accurate list of your student's immunizations, ask your middle school to supply you with a copy of the record on file
with them. Please review that record for accuracy and take it with you to your child's doctor appointment. This will ensure that your child
receives the appropriate immunizations in a timely manner and will eliminate delays in the enrollment process. If you have not received a
copy of your student's immunization record from your middle school, and you or your physician do not have an updated copy, please call
your child's middle school BEFORE MAY 23rd. Documents are not available at the middle school after May 23rd. (Please note that WCCHS
Health Office personnel are not available during the summer to access incoming freshmen health records; be certain that you have obtained
current immunization records from the middle school before the end of this year.) MAKE YOUR APPOINTMENTS FOR THE
PHYSICAL EXAMINATION NOW, in order to avoid delaying your child's start of the school year.
Sincerely,
Annette Snyder, BSN, CSN, MEd.
Health Services
WEST CHICAGO COMMUNITY HIGH SCHOOL
326 Joliet Street
West Chicago, IL 60185
630-876-6200 (Phone)
630-876-6585 (Fax)
Estimado padre o tutor:
Primavera 2016
Dentro de muy poco vamos a recibir a su hijo/a a la Escuela Preparatoria West Chicago Community High School como parte de
la generación 2020 ¡Bienvenidos!
Esta carta es para aseles saber que los requisitos necesarios para su estudiante de preparatoria. Todas las formas requeridas para
inscripciones estarán disponibles en citio-web como parte del paquete de registraciones.
Estos son los documentos que LA LEY ESTATAL requiere para todos los estudiantes comenzando el primer año escolar de
preparatoria:
REQUISITOS PARA EXÁMENES FÍSICOS
Es necesario usar la forma de dos-vistas de los exámenes fisicos, la cual el Departamento de Salud de Illinois (IDPH)
de Certificate of Child Health Examination Form. NINGUNA OTRA FORMA PUEDE SER UTILIZADA.
Cartilla de vacunas; firma y fecha del médico debe estar incluida en el frente de la forma.
Examen fisico reciente por un médico certificado (en el espacio de un año que abarque el primer día de
clases, Septiembre 6, 2016).
El padre/tutor debe llenar la porción de "historial de salud" del examen físico y anotar la fecha y firmar en
el espacio indicado en la parte de arriba de la forma.
REQUISITOS PARA VACUNAS
a.
b.
c.
d.
e.
Comprobante de dos vacunas de paperas, 2 sarampiones, y 2 de rubiola. La primera dosis debe averse
recibido en o después del ler año de edad y la segunda dosis a los 28 días después de la primera.
Comprobante de serie completa (3 dosis) contra dipteria-pertosis-tetano, y que la última haya sido el
refuerzo de Tdap y recibida después de la edad de 4 años, y por lo menos 6 meses después de Ia dosis
anterior.
Comprobante de serie completa de vacunas contra la polio (3 dosis) la última dosis después de los 4
años de edad o por lo menos 6 meses después de la anterior.
Comprobante de serie completa de vacunas contra la hepatitis B (3 dosis) espacios entre la primera y
segunda son 28 días, y entre la segunda y tercera 2 meses y por ultimo entre la primera y tercera son 4
meses.
Comprobante de dos vacunas de (Varicela) la primera dosis después del primer año de edad y la
segunda no menos de 4 semanas después.
AGA SUS SITA PARA EL EXAMEN FISICO YA.
NOTA: Formas incompletas y sin firmar retrasarán la inscripción. Su estudiante NO recibirá su
horario ni información de casillero si las formas no son devueltas o están incompletas.
Si su hijo/a tienen pensado participar en actividades inter-escolares el año próximo, cumplir con el examen fisico de 9no grado será
suficiente para este requisito. Sin embargo, para asegurarse de que el examen fisico es valido hasta la temporada de deportes de
primavera, les recomendamos que hagan el fisico después del 1 de junio de 2016. Por ley, no estamos permitidos aceptar la
forma de deporte físico de IDPH.
USTED DEBE CONTAR CON LOS DOCUMENTOS DE VACUANAS DE SU HIJO/A MAS ACTUALIZADO PARA LA SITA A SU
MEDICO. Para ayudar a asegurarnos de que usted tenga una lista completa de las vacunas de su hijo/a, la escuela Middle School le
está proporcionando una copia de la cartilla de vacunas que ellos. Por favor revise con detalle los documentos y llévelos con usted a
la cita con el doctor. De esta manera asegurara que su hijo/a reciban las vacunas apropiadas en cuanto sea posible y eliminara
tardanzas en el proceso de inscripción. Si usted no recibió una copia de la cartilla de vacunas de la escuela middle school y usted o su
médico no tienen una copia actualizada, por favor llame a la escuela middle school ANTES de MAYO 23. Los documentos no estarán
disponibles después de Mayo 23. (Por favor anote, que el personal de Oficina de Salud de la escuela WCCHS no estará disponible
durante el verano; para tener acceso a los documentos de su hijo/a de 9 grado, revise con atención este documento que obtuvo de la
escuela middle school antes del fin de año escolar.) AGA SU SITA YA PARA EL EXAMEN FISICO, para evitar retrasos en el
comienzo del año escolar de su hijo.
Atentamente,
Annette Snyder, BSN, CSN, MEd.
Servicios de Salud
ATTENTION:
If you are unable to print the necessary medical/health forms that are
needed for your child's health requirements to start 9th grade, a hard
copy will be available in the West Chicago Community High School's
Health Office until the last day of school (June 9, 2016).
From June 9 on, these forms will be available at Entrance H.
ATENSION:
Si no le es posible imprimir las formas medicas/salud necesarias para los
requisitos para su hijo/a para el comienzo de 9 año escolar, tendremos copias
disponibles en la escuela West Chicago Community High School en la
Oficina de Salud hasta el último día escolar (Junio 9, 2016)
A partir de Junio 9 en adelante, estas copias estarán disponibles
en la Entrada H del edificio de la escuela.
PROCEDURE FOR ADMINISTRATION OF PRESCRIPTION
AND NON-PRESCRIPTION MEDICATION
MEDICATION ADMINISTRATION:
Parents and guardians have the primary responsibility for administering medication to their children. Only those
medications absolutely required for the critical health and well being of the student will be administered during
school hours or during school related activities. In order to ensure the safe and proper administration of medication
to students, the following procedures have been established. The intent of these procedures is to protect the student,
to provide a clear and consistent approach to the administration of medication, and to ensure that physician, parents,
school, and student understand their responsibilities.
PROCEDURE:
1.
The parent(s)/guardian(s) and Illinois physician will complete the School Medication Authorization form
before the administration of any non-prescription medication at school. However, if the prescription
medication is an antibiotic that is being prescribed for a short period of time (up to and including 10
days), the parent(s)/guardian(s) may sign his/her permission for the administration of the medications
without a medical doctor’s order.
2.
All prescribed medications will be provided to the school nurse in an original container or vial, as
provided by the pharmacist with the prescription label affixed. Upon request, the pharmacist will supply
you with the properly labeled containers, one for home and one for school. Non-prescription (over-thecounter) medications must be provided in the original unopened container labeled with the student’s
name.
3.
The Medication Authorization Form must be completed annually or whenever there is a change in
medication and/or dosage.
4.
No student may possess or consume any prescription or non-prescription medication during school
hours or school-related activities until a completed and signed Medication Authorization form is on file.
The school nurse may, in conjunction with the physician and parent(s)/guardian(s), identify
circumstances in which a student may self-administer either under the direct supervision of school
personnel inserviced by the school nurse, or an individualized program developed by the school nurse.
The appropriate permission-to-carry form must be completed and on file in the Health Office before the
student may possess or consume any medication during school hours or school-related activities.
5.
It is the parent(s)/guardian(s)’ responsibility to ensure that the licensed prescriber’s order, written
request, and medication are brought to the school. The parent(s)/guardian(s) will be responsible for
taking any unused medication from the school when no longer required. The school nurse will discard
unused medication not picked up by the last day of school.
6.
Medication will be administered under the direction of the school nurse. Questions relating to
medication should be directed to the school nurse.
7.
If parental and physician authorization to self-administer medication is on file in the Health Office, the
student may carry his inhaler or Epi-Pen. No other medication, prescription or non-prescription, may be
in a student’s possession during the school day or at school-related activities.
Community High School District 94
Health Services
Health Office Phone: (630) 876-6245
Fax Number: (630) 876-6585
Reference:
Illinois Department of Human Services and Illinois State Board of Education
“Recommended Guidelines for Medication Administration in Schools”
Asthma Management: A Resource Manual for Schools
PROSEDIMIENTOS PARA ADMINISTRACION DE
RECETAS MEDICAS&POR FUERA DE FARMACIA
ADMINISTRACION/MEDICAMENTOS:
Padres y tutores tienen la resposabilidad de administrar medicamento a sus hijos. Solo aquellos medicamentos que
sean absolutamente requeridos para condicion de salud critica y el bienestar de los estudiantes, searan adminstrados
durante horarios escolares o durante actividades relacionadas con la escuela. Para acegurar la administracion
apropiada sin incidentes, los siguientes procedimientos seran establecidos, la intencion de estos procedimentos son
para la proteccion de los estudiantes y proveer con mejor claridad, consistencia y aprocximacion al administrar los
medicamentos y acegurarnos que los doctores, padres, estudiantes y la escuela puedan comprender sus
resposabilidades.
PROCEDIMIENTOS:
1. Los padres/tutores y los doctores de Illinois antes de administrar cualquier medicamento en la escuela, deveran
completar la forma de administracion medica. De cualquier manera si la receta medica es antibiotico y ha sido
recetada por un periodo corto (inclullendo 10 dias). Los padres/tutores pueden firmar el permiso para
administracion de medicamentos sin la orden de sus doctores.
2. Toda medecina recetada sera entregada a la enfermera de la escuela en un contenido (frasco) tal y como fue
entregado en la farmacia. Si usted pide al farmaceutico que le surta dos contednidos (frasco) uno para la casa y el
otro para la escuela seria mucho mejor. Medecina no rectada devera ser entregada a la enfermera en un frasco
original sellado con el nombre del estudiante.
3.
La forma de autorizacion mendica devera ser completada cada ano cuando cambie de medicamento/docis.
4. Hasta no ser completada y firmada la forma de autorizacion medica, nungun estudiante deve poseer o consumir
medecina receta o comprada durante el horario ecolar/actividades relacionadas con la escuela. La forma devera ser
entregada a la oficina de salud (emfermeria), la enfermeria de la ecuela enconjunto con el doctor y padres/tutores
pueden indintificar la circunstacia sobre cuando el estudiante puede administrarse el medicamento con la
supervision derecta de la escuela, personal en servicio de la enfermera de escuela o algun programa individual
desarrollado por la enfermera de la escuela.
5. Antes de que el estudiante pueda consumir algun medicamento durante horario/actividades escolares, los
padres/tutores son responsables de aseguarse que la resetas medicas o las ordenes sean entregadas a la escuela. Los
padres/tutores seran responsables de llebarse cualquier medicamento que ya no sea necesario cuando ya no sea
requerido. La enfermera de la escuela desechara medicamento recuperado el ultimo dia de clases.
6. Medicamento que necesite ser administrado, sera supervisadao por la enfermera de la escuela. Preguntas en
relacion con el medicamento deven ser dirigidas a la enfermera de la escuela.
7. Si los padres y doctores autorizan administracion propia de medicamentos y la forma de autorizacion medica fue
entregada a la oficina de salud,los estudiantes pueden cargar consigomismos su enalador o Epi-Pen. Ningun otro
medicamento,receta medica devera ser cargado por los estudiantes durante actividades horarios escolares.
Community High School District 94
Health Services
Phone: (630) 876-6245
Fax: (630) 876-6585
Referencias:
El departamento de sevicio de recursos humanos del estado de Illinois y el distrito de
educacion de Illinois.
“Guias recomendadas para administracion de tratamiento medico en la escuela”
El manejo para asma: Un recurso manual para las escuelas.
Medical Information/Release Form
*ALL FORMS MUST BE DATED AND SIGNED*
This medical information and release form is vital in the care of your student while at school. It provides us with information to treat your child
and also includes essential information such as health concerns. If your child needed immediate emergency care, it would be extremely
important for the health office to have this information available.
PLEASE REMEMBER TO PROVIDE UPDATED INFORMATION TO THE NURSE WHEN HEALTH CHANGES OCCUR.
ID#:
STUDENT NAME:
GRADE:
PHYSCD:
EMCD:
D.O.B:
IF NEITHER PARENT/GUARDIAN CAN BE CONTACTED, I AUTHORIZE THE SCHOOL ADMINISTRATION TO TAKE SUCH
EMERGENCY ACTION AS NEEDED.
SIGNATURE OF PARENT/GUARDIAN
DATE:
ALLERGIES:
Insects/Bees:
Severe? YES
NO
Epi-Pen Required? YES
NO
Benadryl Required? YES
NO
Foods (list):
Severe? YES
NO
Epi-Pen Required? YES
NO
Benadryl Required? YES
NO
Medications (list):
Severe? YES
NO
Explain:
Environmental (list):
Severe? YES
NO
Explain:
DOES YOUR CHILD NEED AN ASTHMA INHALER DURING THE SCHOOL DAY OR FOR SPORTS? YES
(If yes, please complete appropriate forms)
PLEASE MARK THE CORRECTIVE DEVICES STUDENT MAY WEAR TO SCHOOL:
GLASSES
CONTACTS
HEARING AID
ORTHOPEDIC AIDES
OTHER
ANY KNOWN HEALTH CONDITIONS:
CURRENT TREATMENT:
ANY ILLNESSES, INJURIES, OR SURGERY SINCE LAST YEAR: YES
NO
(If yes, please explain)
MEDICATIONS TAKEN AT SCHOOL ON A REGULAR BASIS:
Medication:
Dose:
Frequency:
Reason:
Medication:
Dose:
Frequency:
Reason:
Medication:
Dose:
Frequency:
Reason:
MEDICATION TAKEN AT HOME ON A REGULAR BASIS:
Medication:
Dose:
Frequency:
Reason:
Medication:
Dose:
Frequency:
Reason:
Medication:
Dose:
Frequency:
Reason:
DOCTOR:
DR PH#:
Names of siblings living at home (K-8):
DENTIST:
School now attending:
DENTIST PH#:
Grade:
NO
FORMA DE INFORMACION MEDICA
*ESCRIBA AL FECHA Y FIRME*
Esta forma de informacion medica es de mucha importancia para el cuidado de su estudiante durante horarios de clases. Si su estudiante
necesitara el cuidado en un caso de emergencia, seria extremadamente importante que la oficina de salud contara con esta informacion medica
imediatamente.
POR FAVOR RECUERDE PROVEER INFORCION ACTUALIZADA A LA REGISTRADORA DE LA ESCUELA.
ID#:
ESTUDIANTE NOMBRE:
CLASE:
PHYSCD:
EMCD:
D.O.B:
EN EL DEVIDO CASO QUE NO PODAMOS COMUNICARONS CON LOS PADRES/PERSONA CON CUSTODIA, YO AUTORIZO AL
PERSONAL DE ADMINISTRACION DE LA ESCUELA QUE SE ACTUE EN CASO DE UNA EMERGENCIA CON MI ESTUDIANTE.
FIRMA PADRES/CUSTODIA:
FECHA:
ALERGIAS:
Insectos/Abejas:
Severa? SI
NO
Epi-Pen Requiere? SI
NO
Benadryl Requiere? SI
NO
Comidas (por favor anote):
Severa? SI
NO
Epi-Pen Requiere? SI
NO
Benadryl Requiere? SI
NO
Alergia a Medicamento (por favor anote):
Severa?
SI
NO
Medioambiental (por favor anote):
Severa?
SI
NO
DURANTE EL ANO, SU ESTUDIANTE NECESITA ALGUN INHALADOR PARA DEPORTES? SI
(Si la respuesta es si, complete la forma de autorizacion medica.)
NO
POR FAVOR CIRCULE CUALQUIER APARATO, MECANISMO QUE SU ESTUDIANTE NECESITARA EN LA ESCUELA:
LENTES
CONTACTOS
AUDIFONO AUXILIAR
ORTOPEDICO
OTRO
ALGUNA CONDICION DE SALUD (Especifique):
TRATAMIENTO ACTUAL:
ALGUNA ENFERMEDAD, GOLPE SERIO, O CIRUGIA DURANTE ESTE ANO PASADO: SI
NO
(Si la respuesta es si, explique.)
MEDICAMENTO DIARIAMENTE QUE TOME EN ESCUELA:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
MEDICAMENTO DIARIAMENTE QUE TOME EN CASA:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
Nombre de Medicamento:
Dosis:
Frecuencia:
Razon:
MEDICO:
MD PH#:
Los nombres de los hermanos que viven en el hogar (K-8):
DENTISTA:
Ahora asisten a escuela:
DENTISTA PH#:
Clase:
COMMUNITY HIGH SCHOOL DISTRICT #94
HEALTH SERVICES
PARENTAL AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
Phone: (630) 876-6245
Fax: (630) 876-6585
THIS FORM IS REQUIRED IF YOUR CHILD IS TO RECEIVE NON-PRESCRIPTION AND/OR
PRESCRIPTION MEDICATION AT SCHOOL.
STUDENT NAME:
(Last)
DOB:
(First)
(Middle)
ID#:
The following guidelines shall apply to the self-administration of a student’s asthma or severe allergy medication (Epi-Pen):
-
-
An Illinois physician/prescriber signed and dated authorization to administer the medication, setting forth the name and
purpose of the medication, the prescribed dosage, time for administration, and any other special related information with
regard to the administration of stated medication must be on file in the Health Office.
Parent (Guardian) signed and dated authorization to administer the medication must be on file in the Health Office.
The medication is in the original labeled container as dispensed or the manufacturer’s labeled container.
The medication label contains the student’s name, name of medication, directions for use and date.
Annual renewal (with the start of each new school year) of authorization and immediate notification, in writing by the
prescribing physician, of changes.
It is recommended that you provide an additional dose of the medication to be kept at school in the event that your child
forgets or loses his/her asthma or severe allergy medication (Epi-Pen).
The school district and its employees and agents are to incur no liability, except for willful and wanton conduct, as a result of
any injury arising from the self-administration of medication by the student.
PARENTAL AUTHORIZATION:
I hereby acknowledge that I am the parent/legal guardian of the above referenced student and that I am primarily
responsible for administering medication to my child. However, in the event that I am unable to do so, I hereby authorize
Community High School District #94 to allow my child to self-administer his/her lawfully prescribed asthma or severe
allergy medication (Epi-Pen) during the following: 1) while in school; 2) while at a school sponsored activity; 3) while
under the supervision of school personnel; and 4) before or after school activities.
I further acknowledge and agree that Community High School District #94 and its employees and agents are to incur no
liability, except for willful and wanton conduct by any of the said parties, as a result of any injury arising from my child’s
self-administration of asthma or severe allergy medication (Epi-Pen). I further acknowledge and agree that, in absence of
willful and wanton conduct on the part of the school district and its employees and agents, I waive any claims that I might
have against said parties arising out of my child’s self administration of said medication. In addition, I agree to indemnify
and hold harmless the school district and its employees and agents, either jointly or severally, except claims based on
willful and wanton conduct on behalf of said parties, from and against any and all claims, damages, causes of action or
injuries incurred or resulting from my child’s self administration of said medication.
If the medication prescribed is to be self-administered by the student, I authorize and give permission for my child,
to carry and self-administer the asthma or severe allergy medication(s) described on
(Name of Student)
the previous page. I, or my child’s physician, will notify Community High School District #94 of changes in asthma or
severe allergy medication or in my child’s condition.
SIGNATURE:
(Parent/Guardian)
(Home Phone)
DATE:
(Business Phone)
Reference:
Illinois Department of Human Services and Illinois State Board of Education
“Recommended Guidelines for Medication Administration in Schools”
Asthma Management: A Resource Manual for Schools
COMMUNITY HIGH SCHOOL DISTRICT 94
SCHOOL MEDICATION AUTHORIZATION FORM
Phone: (630) 876-6245
Fax: (630) 876-6585
THIS FORM IS REQUIRED IF YOUR CHILD IS TO RECEIVE NON-PRESCRIPTION AND/OR
PRESCRIPTION MEDICATION AT SCHOOL AND/OR CARRY AN INHALER OR EPI-PEN.
STUDENT'S NAME:
STUDENT ID#:
DOB:
DIAGNOSIS:
PHYSICIANS: Please Complete diagnosis (above), items 1 and 2, and sign and date this form.
1. List all medication prescribed to this student:
DRUG
DOSAGE
FREQUENCY
REASON
PRESCRIBED
WHEN REEVALUATION
SIDE EFFECTS
PLANNED
2. List medication that must be administered during School Hours.
DRUG
DOSAGE
TIME TO BE
ADMINISTERED
REASON
PRESCRIBED
SIDE EFFECTS
SPECIAL
INSTRUCTIONS
Permission is granted for professional school personnel to administer drugs as prescribed during the school day.
Medication will be provided by the parent as instructed. If the medication prescribed (inhaler or Epi-Pen only) is to be
self-administered by the student, I certify that
self-administration of
(Name of Medication)
(Name of Student)
has been instructed in the use and
. He/she understands the need for the medication, and the
necessity to report to school personnel any unusual side effects. He/she is capable of using this medication independently.
PHYSICIAN'S SIGNATURE: _______________________________________ DATE: ____________________________
PRINTED NAME OF PHYSICIAN: _________________________________ PHONE NUMBER: _________________