Student Emergency /Medical Information (S-865)
     This form must be filled out every year by parents or guardians to allow the school nurse to medicate their child with Acetaminophen or Ibuprofen 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.  

Sign in to Google to save your progress. Learn more
Student Last Name *
Student First Name *
Student Date of Birth *
School *
Grade: *
Clear form
Never submit passwords through Google Forms.
This form was created inside of School District of Philadelphia. Report Abuse