Life Threatening Allergy Packet Placentino Elementary School Holliston, MA 2016 – 2017

Table of Contents

Letter from the Nurse……………………………………………………………………………………..……1 Placentino Bus Consent…………………………………………………………………………………..……2 Anaphylaxis/Epinephrine Program……………………………………………………………..………..3 Medication Order Form……………………………………………………………………………….……….4

Placentino Elementary School 235 Woodland St. Holliston, MA 01746 Health Office: 508-429-0689 Fax: 508-429-0691 Erica Olson, RN, BSN School Nurse

Dear Parent, I am aware that your child has a potentially severe allergy. In order for me to keep your child as safe as possible while at school, I will need you to complete the following: Parents will provide:     

EpiPen, Epipen Jr, or Auvi-Q Medication Orders for Benadryl and/or Epinephrine Anaphylaxis Emergency Care Plan as found on the Placentino Nurse Website Signed Anaphylaxis Permission letter Bus Driver consent

Cafeteria Accommodations:  Nut Free Zone  General seating The necessary forms can be found on the school website under the Nurse’s Office tab, in the Life Threatening Allergy Packet. I will need you to complete and return the forms when you bring your child’s supplies into school. Thank you for your help in this matter.

Sincerely, Erica Olson, RN, BSN Placentino School Nurse

Dear Parents/Guardians, This letter is to request your permission to inform your child's bus driver about your child's potentially serious allergy and/or medical condition. As the school nurse, I inform teachers and other school personnel about children with special health care needs, especially lifethreatening allergies and other serious medical conditions. Recently the nurses met with our bus drivers to review issues regarding children with lifethreatening allergies or medical conditions. This training is conducted annually prior to the start of the school year. The bus drivers and the nurses agree that it is important for bus drivers to be informed of this valuable information. Before they receive this information they are reminded of their responsibility to maintain confidentiality. We hope that you will complete the consent form at the bottom of the page and grant permission. Sincerely, Erica Olson, RN, BSN Placentino School Nurse

________________________________________________________________________

______ I give permission to the school nurse to inform the bus driver of my child's potentially serious allergy/medical condition. ______ I do not give my permission to the school nurse to disclose this information.

My child's name is ___________________________________. My child rides on bus number __________________________. Parental Signature ___________________________________. Date ______________________________________________.

SCHOOL HEALTH SERVICES Holliston Public Schools ANAPHYLAXIS/EPINEPRHINE PROGRAM Permission to Disclose Emergency Information Please sign under each statement and return to the school nurse.

I give the school nurse permission to give life saving information about my child, ____________________________, to any school faculty who may be present if my child has an allergic reaction. Parent/Guardian signature _____________________________Date_______________________

I give the school nurse permission to use my child’s picture on an emergency information sheet, in order for substitute faculty to be able to quickly identify my child if he/she has an allergic reaction. Parent/Guardian signature _____________________________Date_____________________

I give the school nurse/teacher permission to send a letter home to parents of all students in my child’s class in order to inform them that there is a child with a food allergy, and to enlist their help in keeping certain foods out of the classroom. Parent/Guardian signature _____________________________Date_____________________

MEDICATION ORDER (To be completed by a licensed Prescriber: Physician, Nurse Practitioner, or other authorized by Chapter 94C)

Name of Student_____________________________________________ Date of Birth________________ Address________________________________________________________ Grade _________________ (street)

(city/town)

Name of Licensed Prescriber_________________________________________ Title_________________ Business Telephone Number__________________________________ Emergency Telephone Number________________________________ Medication ____________________________________________________________________________ Route of Administration_______________________________Dosage_______________ Frequency_________________________Time(s) of Administration _________________ Specific directions or information for administration:____________________________________ Date of Order ___________________________________Discontinuous Date _______________________ Diagnosis ______________________________________________________________________________ Consent for self-administration (provided the school nurse determines it is safe and appropriate). Yes_______ No________ _______________________________________________________ Signature of Licensed Prescriber ________________________________________________________________________________________________________

PARENTAL CONSENT 1.

I give permission to have the school nurse or school personnel designated by the school nurse to give the following medicine ______________________________________________________________________ (Name of medication and dose) Prescribed by ________________________________ to ________________________________________ (Licensed Prescriber) (Name of Student)

2.

I give permission for my son/daughter to self administer medication if the school nurse determines it is safe and appropriate. Yes_______ No_______

3.

I give permission to the school nurse to share with the appropriate school personnel information relative to the prescribed medication administration, e.g. adverse side effects, as she/he determines necessary for my son’s/daughter’s health and safety. Yes_______ No_______ Any restriction on release_________________

4.

Daily meds and emergency meds and inhalers will be sent on Field Trips and administered by designated school personnel. Yes_______ No________

Please note: I understand that I may retrieve the medicine from the school at any time and that the medicine will be destroyed if it is not picked up within one week following termination of the order or one week beyond the close of school.

Signature of Parent/Guardian __________________________________________________________________ Relationship to Student _________________________________________ Date ________________________