Warren School District Nurse Information & Medication Administration Form

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NOTE: This parental consent form is only valid for the current school year and must be updated annually.

Email *

STUDENT NAME *

GRADE/ TEACHER *

Emergency contact information in order of preference when child is sick:

PARENT/GUARDIAN NAME AND RELATIONSHIP PHONE NUMBER *

I give permission for the school nurse to administer the following medications(brand name or generic form): *

None

ALL

Acetaminophen (Tylenol)

Ibuprofen (Advil/Motrin)

Cough drops

Benadryl (stings or severe allergy)

Hydrocortisone (anti-itch)

Tums

Aloe Vera Gel (sunburns)

Antiseptic (cuts and scrapes)

Vicks VapoRub

Triple Antibiotic Ointment

Calamine Lotion (anti-itch)

Visine (red eyes)

Orajel (tooth aches)

Required

ALLERGIC to these Medications: *

ALLERGIC to these Foods:

(Please provide a signed doctor's note stating allergies)

List any medications that your child takes daily at HOME: *

I will/have receive(d) and review(ed) the Warren School District nursing policies in the WSD handbook: (Available online or hard copy available in school office.)

I give permission for the above named student to be given first aid if deemed necessary by the Warren School District staff trained in first aid procedures. I acknowledge that the Warren School District, its Board of Directors, and its employees shall be immune from civil liability for damages resulting from the administration of medications and/or first aid in accordance with this consent form.

I also do hereby authorize officials of the Warren School District to directly contact the physician and/or the hospital and give the physician and/or hospital staff permission to render such treatment that may be necessary in an emergency for the health of the above named child. In the event that parents, physician, or authorized persons cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary for the health of my child. I will not hold the school district financially responsible for the emergency care and/or transportation for my child.

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