Student Emergency/Medical Information (S-865)

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This form must be filled out every year by parents or guardians to allow the school nurse to medicate their child with Acetaminophen, Ibuprofen, Albuterol or Epinephrine (EpiPen) as prescribed by the School District’s medical Officer/pediatrician. Nurses cannot administer this medication without parental permission.

This form also gathers information about a child’s health history. This information can be vital in case of emergency or should the need for any type of medical treatment arise while a child is in school.

Email *

Student Last Name *

Student First Name *

Student Date of Birth *

YYYY

School *

Room/Sec:

Grade: *

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