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
STUDENT NAME: _________________________________________ GRADE: __________