Instructions for completing


Please fill this tan form out if your child is currently on a prescription or an over-
the-counter medication. Otherwise, please hold on to it with these directions for
future use.
General things to know:

This form is to be completed only when teachers will need to administer either over-the-counter medications or prescription medications Each medication requires a separate form All medications are to be given directly to your child’s teacher and can not be kept in your child’s cubby or backpack The medication must in the original container with your child’s name on The WCCC fax number is 413-597-4889 (machine is turned off and will not receive faxes until after 8:30 a.m.)
Prescription Medications

The form must be filled out with your child’s name and the name of the prescription medication and signed by you The prescription label serves as the doctor’s directions and “signature” so the doctor does not need to fill out the remaining form All prescription medications must be in the containers in which they were originally dispensed and with their original labels affixed
Over-the-Counter Medications

Unanticipated Use of OTC Medication (such as Tylenol for unexpected
head ache or Benadryl for unexpected allergic reaction – medicines provided by parents/guardians) o Please sign and submit one form per medication o The form is also to be signed by the doctor with directions to be o OTC medication forms for unanticipated use can be signed once Anticipated Use of OTC Medication (when your child is given an OTC
medication because they have a current illness for which they need medication - like a cold medication) o Please sign and submit one form per medication o The form is also to be signed by the doctor with directions to be o You must submit a new form for each week we are to administer the medication (Exception to this is only made if it is noted by the doctor on the form that the medication is being prescribed indefinitely for an on-going medical condition) Over-the-counter medications must be in the original manufacturer’s
Topical Medications:

o Permission for us to apply topical products such as sunscreen, insect repellent and OTC diaper ointment is given when you sign the pink “Informed Consent” form and is good for one year o Parents supply teachers with all such products to be kept in the teacher’s o Even things like chap sticks and hand sanitizer are to be given to the
Reminder for Illnesses:

o If your child is ill with a fever or has a fever from an immunization or teething, he/she must be fever free for 24 hours WITHOUT fever reducing medication before returning to school o If you child is ill with diarrhea or vomiting, he/she must be symptom free
Serious Medical Conditions (such as allergies or seizures)

o Please ask for an allergy or seizure action plan to be filled out by your o Please also sign the form yourself o Forms are good for one year or until treatment for condition changes o Medications for serious medical conditions such as Epipens for allergies must also have your child’s photo on the box or container o Epipens need to be changed every six months Please let us know if you have any questions. Thank you. (9-21-10)



Complemento Declaración Juramentada sobre el Estado de Salud La resolución 5261 de 1994 establece que “toda persona que ingrese a una EPS, debe diligenciar bajo la gravedad de juramento, un formulario que contenga sus datos personales y familiares, su condición de salud actual y pasada así como la de los familiares que vaya a inscribir, los antecedentes familiares y personales,

“1st WORLD MEETING ON LASERS, LASERTHERAPY, Congress Center Sheraton Hotel – Catania Chairs: Bartolomucci Giorgio, Bencini Pier Luca, Bonan Paolo, Campolmi Piero, Cannarozzo Giovanni, Dattola Santo, Ferrari Angelo, Lopreiato Raffaele, Nisticò Steven, Petrini Nerella, Piccolo Domenico, Sannino Mario, Zagni Giovanni Fabio, Zerbinati Nicola. 1) Surgical lasers and fractional laser Cannarozzo

Copyright ©2018 Sedative Dosing Pdf