Health Form 2026-2027

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<b>Our Lady of Mount Carmel Catholic School</b><div><span><b>Emergency Health Information</b></span></div>

Family Last Name *

Preferred E-Mail *

Mother's Name (First Last) *

Mother's Phone Number *

Father's Name (First Last) *

Father's Phone Number *

Pediatrician *

Pediatrician's Phone Number *

Parent Consent for Medication Administration, Release of Medical Information and Emergency Treatment *

I authorize the school nurse to administer over-the-counter medication per package dosage and schedule recommendations. Over-the-counter medications are supplied, by me, for my child and are delineated on the back of this form.

I authorize the school nurse to administer prescribed medication when ordered. I will supply medication in the original container with a pharmacy issued label and accompanied with a physician’s order.

I permit medical information to be shared as appropriate, with involved school staff, faculty and coaches.

I permit the school nurse, or principal designee, to care for my child/children if illness occurs during the school year. I authorize the School Nurse, or principal designee, to obtain emergency treatment for my child/children if unable to contact a parent/legal guardian.

I permit the school nurse to contact my child/children’s health care provider for medical direction, immunizations and information updates.

If the nurse is not available, I permit an OLMC Staff member designated by the principal to administer the appropriate medication and care listed above.

Parent/Guardian Signature

Student 1 First Name *

Student 1 Last Name *

Student 1 Grade *

YYYY

Student 1 Date of Birth *

YYYY

Student 1 Past Medical History (Check all that apply)

Life Threatening Allergy

ADD/ADHD

Asthma

Diabetes

Epilepsy/Seizure Disorder

Heart Defects/Heart Murmur

Fractures/Bone Disease

Skin Disorders/eczema

Migraines/Frequent Headaches

Recurrent Ear Infection

Head Injury/Concussion

Mental Health (Anxiety, Depression, OCD)

Wears Glasses/Contacts

Braces/retainers

Hearing Aids

Spectrum Disorder

Other:

Please explain any condition checked above

Student 1 Food Allergies *

Student 1 Drug Allergies *

Student 1: Current Medications

Please list any current medication the student is currently taking, including the dosage, time given and reason for medication.

The following are common medications and treatments. Please check all that you give permission for your child to receive.

I give permission for all items listed below

Acetaminophen (i.e. Tylenol)

Ibuprofen (i.e. Motrin)

Antacids (i.e. Tums)

External Ointment/Sprays (antihistamine itch cream, neosporin)

Cough Drops/Lozenges

Sterile Eye Drops/Eye Flush

Wound Washes

Diphenhydramine (i.e. benadryl)

Sunscreen

Do you have another student at OLMC? *

Yes

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