MJS - Outdoor Education - Medical Information Form
Memorial Junior School - Authorization for Medical Treatment of a Minor Temporarily Separated from Her/His Parent/ Guardian - Must be completed by June, 30, 2017
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Please review the following medication guidelines:
 All medications must be provided to the school nurse by October 14, 2017 in its original packaging. Parent/Guardian may also bring medication to the Orientation Night (in Fall 2017), as the MJS Nurse will be present.

 A completed "Request for Administration of Medication by the School Nurse/Registered Nurse" form must accompany each medication and must be signed by both the parent/guardian and the student’s physician.

 Board of Education policy stipulates that students who are permitted to self-administer their medication (for asthma, bee stings, or any another potential life-threatening illness) must have their parent/guardian complete the "Request for the Self Administration of Medication" form. If an Epi-Pen is needed, an additional form entitled “Emergency Administration of Epinephrine via Epi-Pen” is also required.

Medication Forms are located in the MJS Health Office, MJS website, or in the MJS Main Office, over the summer. If you have any questions, you may contact our MJS Nurse (Ms. Gioia) at 973-515-2431 during the school year.

Please complete the following form by June 30, 2017, in order for your child to attend the 2017 MJS Outdoor Education Experience! The contents of this form are kept confidential and will be managed by the Program Coordinator and MJS Nurse.
Student - Last Name
Your answer
Student - First Name
Your answer
Student - Date of Birth
Your answer
Student - Address
Your answer
Home Phone #
Your answer
Parent/Guardian #1 - Last Name
Your answer
Parent/Guardian #1 - First Name
Your answer
Parent/Guardian #1 - Cell Phone #
Your answer
Parent/Guardian #1 - Work Phone #
Your answer
Parent/Guardian #2 - Last Name
Your answer
Parent/Guardian #2 - First Name
Your answer
Parent/Guardian #2 - Cell Phone #
Your answer
Parent/Guardian #2 - Work Phone #
Your answer
Emergency Contact #1
Your answer
Phone #
Your answer
Emergency Contact #2
Your answer
Phone #
Your answer
STUDENT MEDICAL SERVICES AUTHORIZATION
If I/we cannot be reached, I/we authorize Justin Toomey (Assistant Principal) or Brenda Talbert (Outdoor Education Coordinator) to authorize medical services for my child. This includes: consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor, at a recognized medical facility, under the general or special supervision of a licensed physician or surgeon.
Physician Name
Your answer
Phone #
Your answer
STUDENT INSURANCE INFO
Company
Your answer
Group #
Your answer
Identification #
Your answer
STUDENT MEDICAL NEEDS
Student Allergies (medications, insects, foods, etc.) - IF NONE, TYPE "N/A"
Your answer
What are common symptoms?
Your answer
What are treatment options? (i.e. Epi-Pen)
Your answer
Medical Conditions - IF NONE, TYPE "N/A"
Your answer
Please list any medication(s) the student will be taking during Outdoor Education. A doctor’s note is required and must be provided with each medication. Medication Forms are located in the MJS Health Office, MJS website, or in the MJS Main Office.
Your answer
Food Restrictions: (low fat, vegetarian, lactose intolerant, gluten free, allergies, etc.) - IF NONE, TYPE "N/A"
Your answer
When was the student's most recent Tetanus shot?
Your answer
OTC MEDICINE CONSENT
You have permission to give my child Tylenol
You have permission to give my child Benadryl.
PARENT/GUARDIAN ACKNOWLEDGEMENT
This eSignature will serve as your official consent and authorization to all terms and conditions, as stated, on this form.
Required
eSignature
Your answer
This authorization will be in effect while the student attends the Memorial Junior School - Outdoor Education Experience from Wednesday, October 18 - Friday, October 20, 2017.
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