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Octorara.k12.pa.us2

STUDENT NAME: _________________________________________ GRADE: __________
EXPLANATION OF HEALTH SERVICES

Octorara Area School District nurses provide the following health services in accordance with
Pennsylvania State Law:
Administer first aid and illness care. Administer medications per physician orders. Maintain student health records. Administer pediatric nursing procedures. Conduct mandatory screenings: o Every year, every student:.Height, weight, and vision screening o Grades Kdg., 1, 2, 3, 7, and 11.Hearing screening o Grades 6 and 7 .Scoliosis screening Monitor physical exams required in grades Kindergarten, 7, and 11. Monitor dental exams required in grades 1, 3, and 7.
I understand the above health information will become part of my child’s permanent school
health record.
Parent/Guardian Signature ____________________________________ Date: ___________

PERMISSION FOR TREATMENT AND CARE

I give my permission for _________________________________________________________
(Please write first and last name of student) to receive the following health care services by the Octorara Area School District’s health offices. Routine and emergency first aid. Routine sick care. Mandatory state screenings.
I will notify the school if I change my mind about giving permission for any of the stated health
care services during the above student’s career at Octorara School District.
Parent/Guardian signature _____________________________________ Date: ___________
Octorara Area School District
Confidential Information For The School Nurse
Student Name ______________________________ Date of Birth _________ Grade _____ HR _____ Is this child covered by health insurance?
Allergies:
 yes  no Bee Sting Allergy? Reaction _______________________________________________
Previous treatment ______________________________________________________  yes  no Medication Allergy? List _________________________________________________
 yes  no Food Allergy? List ______________________________________________________
 yes  no Other Allergy? List ______________________________________________________
Medical Conditions: (check all that apply)
 ADD/ADHD
 Cardiac Problems  Diabetes  Seizures  Chronic Illness, explain ____________________________________________________________
 Emotional/Behavioral Concerns, explain _______________________________________________
 Special Conditions, explain _________________________________________________________
Assistive or Support Devices: (check all that apply)
 Glasses
 Contacts  Hearing Aid(s)  Wheelchair  Crutches  Other, explain ____________________________________________________________________
Medications: please list all medications (if you need more room please write on the back of this form)
Medication
Diagnosis
Permission For Medication Dispensed By The School Nurse:
 yes  no Tylenol  yes  no Benadryl
 yes  no Ibuprofen  yes  no TUMS

I understand that ALL medications, prescription and non-prescription, must be brought to the
Nurse’s Office to be stored and dispensed as required. All medication must be in the original or
pharmacy-labeled container
accompanied by a written permission from a parent/guardian and/or
a doctor.
 yes  no I give permission for the school nurse to obtain/release information regarding medical
conditions, medication permissions, immunizations, and physicals from/to my child’s health care provider(s).  yes  no I give permission for the school nurse to share medical information, as necessary,
Who should be the first person contacted in case of illness or emergency?

Name __________________________ Relationship _________________ Phone _________________

Parent/Guardian Signature ______________________________________ Date ______________

  • /Octorara Area School District Office
  • HOME PHONE HOME PHONE HOME PHONE
  • CELL PHONE CELL PHONE CELL PHONE
  • LANGUAGE SPOKEN AT HOME: ( ENGLISH ( SPANISH ( OTHER
  • IS THIS CHILD COVERED BY HEALTH INSURANCE? YES NO
  • OPERATIONS EYES VISION GOOD YES NO
  • Signature of Parent/Guardian/Foster
  • Source: http://www.octorara.k12.pa.us/cms/lib07/PA01916570/Centricity/Domain/30/Health%20Forms.pdf

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