LUNENBURG PUBLIC SCHOOLS

STUDENT EMERGENCY DISMISSAL AND CONSENT FOR EMERGENCY CARE--- Please complete and return to school

GRADE/ROOM__________

Student’s Name___________________________________________________M or F Date of Birth___/___/___ Restraining/Custody Disputes? Y or N Student’s Address_______________________________________ Town/Zip_________________________ Home Telephone ______________________ To school: Bus #___ Walk ☐ Drop-off ☐ Other_______ From school: Bus #___Walk ☐ Pick-up ☐ Other______Student lives with: Father ☐ Mother ☐ Both ☐ Other________

Siblings and schools (if applicable):________________________________ ______________________________ ______________________________ (Name/School/Grade)

(Name/School/Grade)

(Name/School/Grade) Parent/Guardian

Information: Prioritize by number, best contact 1st, 2nd or 3rd. Check if Authorizing to be contacted using automated dialing equiopment (School Messenger)

# Parent: Mr/Mrs/Ms: 1 Address:

# 2

Parent: Mr/Mrs/Ms: Address:

Guardian Name: Address:

Home# Work# Cell # Email Name of person(s) to be notified (local relative or friend) in case of emergency, accident or illness, when a parent is unable to be reached. Your child will only be released to the care of those listed unless other arrangements are made:

1. __________________________________________________________Phone #________________________ Cell # ________________________ Name

Relationship

2. __________________________________________________________Phone #________________________ Cell # ________________________ Name

Relationship

Student’s Physician __________________________________________ Phone # _______________________ Date of Last Physical? _______ Medical Insurance Do you have medical insurance? YES/NO Do you wish to have information on Mass Health? YES/NO Name of Company ________________________________________ Policy #_____________________ Dental Health

Subscribers Name__________________________________

Do you have dental insurance? YES/NO Student’s Dentist ________________________ Phone # ________________________Date of Last Dental Exam ________

Medical Release: I, _____________________________________, legal guardian of ____________________________, grant the Lunenburg School District personnel, the right to obtain emergency medical treatment for my child during the period of the school year.

I give permission for ambulance transportation to the nearest hospital. Payment for any and all medical treatment that is not covered

by insurance is the financial responsibility of the parent/guardian. Date ____/____/____ Parent/Guardian Signature _______________________________________________________

Permission to release Confidential Health Information: The follow permission is required in order to comply with the Health Insurance Portability and Accountability Act of 1996 that protects your rights as individuals. Please check one and sign below.  I give permission to the school nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs.  I do not give permission to the school nurse to share information relevant to my child’s health condition with appropriate school personnel when needed to meet my child’s health and safety needs. I am returning this form in a sealed envelope addressed to the school nurse.

Signature _______________________________________________________________________ Date ____/____/____

CONFIDENTIAL HEALTH INFORMATION

HEALTH CARE PLAN ON FILE? YES / NO

ALLERGIES: Check specific allergies

(Office use only)

Insect Stings Tree Nuts Peanuts Other Foods _______________________________ Medications/Antibiotics ________________________ Environmental ____________________ Other _________________Describe your child’s allergic reaction ___________________________________________ Indicate treatment for allergic reaction at school ____________________________________________________ Is EPI-PEN required? ______(MD forms required) ILLNESS/CHRONIC CONDITIONS: Check specific conditions

Asthma Other Respiratory Conditions ___________________________ Bone or Joint Disease/Injury Communicable Diseases ______________________ Seizures____________ Diabetes Ear Infections Throat Infections Frequent Headaches Kidney Problems Heart Problems Menstrual problems Accidents Past head injuries_______________ Other Specify _____________________________________________________ Does your child have any present limitations that may require program/classroom/athletic modifications or restrictions? Yes / No If yes, please specify ______________________________________________________________________________________ MEDICATIONS:

List all medications your child takes at home and/or at school: Home ________________________________________________________ School _______________________________________________________

ASSISTIVE DEVICES: Check specific conditions

Eye Glasses for

Distance

Reading or

Both

Other Agencies Involved? DCF DMH DMR DYS Counseling Other

Contact Lenses

Hearing Loss/Aids: Right / Left

Crutches

Wheelchair

Contact Name

Other____________

Contact Number

PERMISSION FOR OVER THE COUNTER MEDICATIONS DURING SCHOOL HOURS MGL Chapter 112, Section 80B requires physician and parent permission for any medication administered in schools. Our School Physician, Dr. M. Lyons, has agreed to grant Physician permission for the administration of the following over the counter medications in school at the discretion of the School Nurse, with WRITTEN PARENTAL PERMISSION. If a parent/guardian chooses to give permission, this form must be completed and returned to the School Nurse. Medication will only be given with written permission on file. My child, ___________________________________________, may be given the following over the counter medication(s) in the health office after an assessment by the nurse.

Grades PK-3rd

Medication

Calamine/Hydrocortisone Cream Triple Antibiotic Ointment Lip Ointment

YES

NO

Grades 4th-12th

Medication

YES

NO

Acetaminophen/ Tylenol Ibuprofen/Advil Tums Benadryl Cough Drops/Throat Lozenges Calamine/Hydrocortisone Cream Triple Antibiotic Ointment Lip Ointment Antihistamine Eye Drops

Parent/Guardian signature: ____________________________________________________

Date: __________________________________