Acton-Boxborough Regional School District Community Education 15 Charter Road, Acton, MA 01720 978-266-2525 fax: 978-266-2540 www.abce.abschools.org
2016-2017 Dear Parents, Please complete only if your child needs an inhaler or epipen or allergies: ____________an Epipen ____________an Inhaler ____________Has Several Food Allergies – Due to the nature if your child’s food allergies, we request that you provide snack. You may bring it to Extended Day and store it here. If your child is not allergic to fruit juices, vegetables and other fruits, s/he may eat those things from Extended day. We have begun this policy as a safety precaution for the children. There are many children with many food allergies, and it has become increasingly difficult to determine ingredients that may be contained in foods served, particularly crackers, cookies, etc. We appreciate your understanding. Teachers will be sensitive to your child’s needs at snack time. We must have Physician Orders on file for any medication, Inhaler, or Epipen (please contact your pediatrician or allergist). You may give us a current copy of the Physician’s Order that you provide to the school. Additionally, please fill out the enclosed form and return it to the office immediately. You will need to provide the device or medication that your child will need. Please bring any device/medication to the Community Education office before the start of school. We need to be aware of this information before the school year begins. Children are not allowed to transport medication. Medication must be in its original container, please. Please contact me if you have any questions. Thank you.
Kate Murray, Coordinator Acton-Boxborough Community Education
[email protected]
Our Mission is to prepare all students to attain their full potential as life-long learners, critical thinkers, and productive citizens of our diverse community and global society.
Acton-Boxborough Regional School District Community Education 15 Charter Road, Acton, MA 01720 978-266-2525 fax: 978-266-2540 www.abce.abschools.org
ACTON-BOXBOROUGH COMMUNITY EDUCATION MEDICATION PERMISSION, 2016-2017 FOR EXTENDED DAY Any medication to be taken at the Extended Day program must be brought in an original prescription container, with enough medication for 1 day, only. We must have Physician Orders on file for medication, or Inhalers, or Epipens (please obtain from your pediatrician or allergist). The empty container will be returned to home each day in your child’s backpack. Please bring all medication to the Community Education office (before the start of school), or give all medication to your child’s teacher. I understand and agree that my child will self-administer the following medication, under the direct supervision of the program adult teachers. There is not a nurse on duty at the program: Child’s Name: _______________________________________________________________ Address: ____________________________________________________________________ Name of Medication #1 ________________________________________________________ Dose: _______________________________________________________________________ Time(s) medication should be taken: ______________________________________________ Dates medication will be taken: __________________________________________________ All days my child is present in the program OR On the following date(s): ___________________________________________ Name of Medication #2 _______________________________________________________ Dose: ______________________________________________________________________ Time(s) medication should be taken: ______________________________________________ Dates medication will be taken: __________________________________________________
All days my child is present in the program OR On the following date(s): ___________________________________________ If your child carries an EpiPen, you need to give staff permission to administer it in an emergency please use above form, AND describe conditions/symptoms under which EpiPen should be administered ___________________________________:_________________________________________ ____________________________________________________________________________ Please note that 9-1-1 will be called in the event that we must use an EpiPen. If your child carries an inhaler, please describe the conditions/symptoms under which your child will selfadminister the inhaler: ____________________________________________________________________________ Parent Name (please PRINT) ____________________________________________________________________________ Parent Signature Date
Our Mission is to prepare all students to attain their full potential as life-long learners, critical thinkers, and productive citizens of our diverse community and global society.
