Sturgis Charter Public School-West Emergency Medical Form For Returning Students
Please complete this emergency medical form for your child returning to Sturgis West in one setting as you can not edit or change the information after you submit the form. If you need to make changes after you have submitted the form, please contact the school nurse. Please be assured that your responses will only be seen by the school nurse, are password protected, and will only be shared with school staff by the school nurse on a need to know basis (only when they will be providing direct supervision to your child).
Email address *
Student's First Name: *
Your answer
Student's Last Name: *
Your answer
Student's Date of Birth: *
My child is in: *
List of allergies (if your child does not have any allergies please write no known allergies): *
Your answer
Updates to Medical History
Please indicate any updates to your child’s medical history from last year (.i.e. primary care physician, insurance changes, medication changes, new medical concerns etc.):
Your answer
Non-Prescription Medication Consent:
The school nurse may assess and administer up to seven doses of the following over the counter medications to my child during the school year; Tylenol (acetaminophen) 325 mg-650 mg (1-2 tablets) every 4-6 hours, Motrin (Advil/ibuprofen) 200 mg-400 mg (1-2 tablets) every 6-8 hours, Cough drops 1-2 as needed, and Tums (calcium carbonate) 500-1000 mg (1-2 tablets) as needed.

I understand I will be notified if my child exceeds the seven dose limit and asked to sign and return the Non-Prescription Medication Consent and Order form to the school nurse. The school nurse will then forward the form to my child’s physician to obtain a medication order for the medications listed above.

I give my consent for medication to be administered to my child under the following conditions...
Your answer
Emergency Contacts:
Please list someone other than yourself to be called in case of an emergency and the school is unable to reach you. Type in the text box below the person's name, relationship to your child, and phone number with area code.
Emergency Contact 1 *
Your answer
Emergency Contact 2 *
Your answer
Parental Releases:
Please read the following statements:

1. By providing my digital signature below I agree that although my child’s health information is confidential, it may be shared on a need to know basis with school staff including substitute nurses and my child's teacher. A copy of this information may be given to a school staff member accompanying my child on a field trip or school outing. A copy of this information will be given to EMS in the event of an emergency.

2. By providing my digital signature below I understand that in case of illness or injury to my child, the school will make every effort to notify me. If I can not be reached, the school will notify the emergency contacts listed above. In the event that emergency medical care is necessary and I cannot be reached, I grant full power to Sturgis Charter Public School to contact emergency medical services and/or arrange transportation to the nearest medical facility for treatment and sign releases as required by the medical facility to obtain any medical or surgical treatment in the judgment of medical authorities at the facility.

Parent/Guardian, please type your full name and the date below. This will serve as your digital signature. *
Your answer
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